With over a million knee arthroscopic surgeries performed in the United States every year, at this point just about everyone has heard about someone having their knee "scoped." This is a quick, low risk procedure that provides relief in the majority of patients.
Why then am I finding myself spending increasing amounts of time talking patients out of this procedure?
It is important to understand what can be done to a knee with the arthroscope.
It is crucial to understand one very important thing that can NOT be done with the arthroscope.
We can not "remove," "clean-up," or otherwise fix arthritis.
Arthritis involves the permanent loss of articular cartilage. This is the cartilage cushion that coats the bone ends as they meet within the joint. Once articular cartilage is gone, it is gone. The solution when symptoms are unacceptable is joint replacement. Not arthroscopy.
So what does all of this have to do with the meniscus?
Let me describe an extremely common situation I encounter in my practice. A patient presents to my office with chief complaint of "torn meniscus." They have already had an MRI scan done. Indeed, contained within this report there is reference to a "meniscal tear." There is often reference to some degree of chondromalacia, articular cartilage degeneration, exposed bone, bone marrow edema, or subchondral cysts. All of these terms are essentially saying: "osteoarthritis."
I always look at these MRI images with patients. I describe all of these pertinent findings. I explain that when there is arthritis in the same knee compartment as a meniscal tear, the pain is most likely due to the arthritis. Even if the meniscus is contributing to the pain, removing it will in no way guarantee pain relief. Many times at this point I am then asked, "so can you clean up the meniscal tear?" It is this fixation on the meniscus that I am attempting to correct. It is crucial to understand that surgically treating a degenerative meniscal tear in an arthritic knee is unpredictable at best. A patient anticipating a miraculous cure can easily be disappointed with the result.
One of the most important studies we do is standing knee x-rays. Bone partially blocks x-rays whereas cartilage does not. When standing, a healthy knee has a clear separation between the femur and tibia. This separation is known as the joint space. It shows us how much articular cartilage there is. This joint space is not the meniscus, it is articular cartilage. When this joint space becomes narrowed, we know there is some arthritis. The term "bone-on-bone" arthritis refers to the complete loss of joint space on a standing knee x-ray. This is what severe arthritis looks like.
A good candidate for meniscal surgery is a patient who has been experiencing ongoing pain, swelling, and who has tenderness to palpation over the involved joint line. This is usually made worse by crouching or twisting. Standing x-rays should not reveal much, if any joint space narrowing. An MRI scan should not show articular cartilage loss or bone marrow edema. In this situation, a knee arthroscopy is a low-risk, high-reward procedure.
,It has been customary for decades to use a pneumatic tourniquet during total knee replacement surgery. Inflation of the tourniquet initiated the very first total knee replacement I saw as a medical student, every total knee replacement I did during training, and nearly every total knee I performed while in practice.
The perceived benefit of tourniquet use was reduced blood loss and better visualization of the tissues during surgery.
Total blood loss is defined as any blood loss during surgery, PLUS any postoperative blood loss into dressings or drains, or into the joint or leg. This can be quantified by comparing pre-operative hematocrit (blood count) with the lowest post-operative hematocrit.
A recent paper suggests that total blood loss paradoxically INCREASES if a tourniquet is used during surgery. A variety of additional recent papers suggest the same thing. How can this be?
Reactive Hyperemia (a period of increased blood flow after tourniquet release)
While a tourniquet is inflated, arterial inflow to the limb is stopped. This is nice for the surgeon during the operation as visualization is easier, and no time needs to be spent controlling bleeding. Many surgeons release the tourniquet at the conclusion of the operation, but prior to closing the incision. This allows any bleeding to be controlled. This was what I always did, because I wanted to be sure all active bleeding was stopped prior to wound closure. I hoped to minimize any post-operative bleeding as well as total tourniquet time. Some surgeons do not choose to do this but maintain the tourniquet until a compressive dressing has been applied.
The problem is that after the period of ischemia (no blood flow), the tissues demand more blood supply, and the blood flow to the limb increases for a period of time after surgery. This is known as reactive hyperemia. As a result, sometimes after surgery, blood will collect in the knee, accumulate in the dressing, and/or be removed in a drain. This can be uncomfortable for patients and it increases total blood loss.
There are other downsides of tourniquet use. Intravenous antibiotics are given just prior to initiation of surgery to help reduce the chance of infection. While this medication is infused prior to tourniquet inflation, once the tourniquet is inflated, blood is no longer circulating and thus, antibiotic medication is not circulating either. Ischemic tissues will become cold making cellular activity and enzymes less effective. Ischemia is stressful to the tissues. This increases inflammation. The tourniquet applies significant pressure to the soft tissues. This can contribute to pain and bruising of the thigh postoperatively. Because the tourniquet stops blood flow, it also increases the chance of blood clot formation.
I encountered occasional cases where the tourniquet didn't work well. This can happen if a patient has high blood pressure, their arteries are calcified, or if their thigh is large. In these cases the tourniquet restricts venous outflow but allows arterial inflow since arterial pressure is higher. We refer to this as a "venous tourniquet." When this happened I would drop the tourniquet and carry on as usual. The operation went fine. A bit more time was needed to stop bleeding during surgery, but the results were no different than when using a tourniquet.
Based on this, the theoretical negative tourniquet effects, and the recent papers suggesting tourniquet paradoxically increases total blood loss, I decided to stop inflating the tourniquet for total knee replacements.
I spend a few more minutes controlling bleeding during the surgical approach. Once this initial bleeding is controlled, there is minimal ongoing blood loss for the remainder of the case. This is analogous to total hip replacement where tourniquet use is impossible due to the location of surgery.
Visualization is excellent. The bone ends are irrigated using pulsatile lavage, and dried as usual prior to implanting the knee replacement components. By this stage of the operation, the knee looks basically the same as it does when using a tourniquet. Prior to closure, all bleeding has stopped. No drain is necessary. Tranexamic acid is a medication that helps reduce blood loss, and we use this in most patients.
I have been very pleased with the results since I have discontinued routine use of the tourniquet for total knee replacement surgery. I found patients are more comfortable and there is noticeably less swelling and bruising. Knee range of motion has been returning quicker.
We are continually working on process improvement to allow patients to return to their normal life as rapidly as possible. This begins with preoperative education, continues with a multimodality pain management plan, a 3-dimensionally planned, robotically assisted joint replacement operation, and early mobilization. My experience is that discontinuing use of the pneumatic tourniquet is yet another step to help patients recover quicker.
Nearly every patient will experience some degree of permanent numbness on the lateral (outside) side of the knee after knee replacement surgery. This is anticipated. It is so common, most surgeons do not discuss this with their patients prior to surgery. It is not a complication, but a necessary side-effect of achieving a safe exposure to perform knee replacement surgery.
What is going on?
There are cutaneous (skin) nerves that cross the front of the knee from the inside (medial) to the outside (lateral). A knee replacement incision is made longitudinally over the front (anterior) of the knee. These small nerves must be cut to allow deeper exposure. Other than a numb patch on the outside of the knee, there is generally no other negative effect.
Once rehabilitated, patients rarely even mention this finding. Most are just thrilled their arthritic pain is gone and they are back to their desired activities again.
I am thrilled to announce my selection as a "top doc" in orthopedic surgery by Hudson Valley Magazine for 2017!
The majority of my orthopedic surgical practice consists of arthroscopic surgery and total joint replacement. During surgery, I use a robotic system that allows me to perform knee and hip joint replacements with extreme precision. Total and reverse total shoulder replacements are also common procedures for me.
Shoulder and knee arthroscopy allows minimally invasive treatment of rotator cuff tears, shoulder instability, cruciate ligament and meniscal pathology.
My collaborative approach allows customization of treatment to meet my patients personal goals. I make a great effort to educate and answer all questions so an individual patient's treatment makes sense to them.
I am very fortunate to be able to solve orthopedic problems for people, and to improve their quality of life. Public recognition like this is a great honor to me.
The future is here!
We are thrilled to announce that we are establishing a robotically assisted total joint replacement program here in Hudson, New York. We will be using the Stryker Mako system for partial knee replacements, total knee replacements, and total hip replacements.
What is the big deal?
Patients and surgeons are very fortunate in that total joint replacement is reproducible, predictable and forgiving. That does not mean it is perfect.
While patients routinely report dramatic pain relief once rehabilitated, we as surgeons are thrilled when they report that their new joint feels "normal." This occurs less often than anyone would like.
During surgery, we use alignment guides designed to produce certain angles, or remove a particular amount of bone. These guides have been the same for decades. Good surgeons will achieve consistent results, but even the very best surgeons will admit that there is more variability than anyone would like. This can occur for a variety of reasons, but it is impossible to completely avoid.
Using a robotic arm during surgery, we can implant joint prostheses within a millimeter and a degree of the intended plan. Every time. No surgeon, anywhere, can do this using manual tools.
Before you begin imagining a robotic arm like those seen in vehicle assembly, let me explain how the Styker Mako robotic arm works. Preoperatively, the patient undergoes a CT scan. The surgeon then plans the surgery virtually on the computer, determining the intended alignment and position of the prosthesis. In the operating room, the surgeon makes the surgical approach and then uses a probe to orient the robotic software to the position of the patients bones. During preparation of the bone, the robotic arm prevents anything but the exact plan from being executed. It does this passively. At no point can the robot move itself. The surgeon positions the tools and prostheses and once perfectly aligned, the robot locks the tool into this perfect position. The handpiece, which is operated by the surgeon, will not be activated until it is perfectly aligned and in a safe position. The surgeon then activates the tool, or manually impacts the prosthesis depending on the step in the procedure. The surgeon gets real-time information regarding implant position as it is happening.
From the surgeon's perspective, this information is invaluable! We can adjust our plan intraoperatively if needed. We can execute our plan perfectly, every time. During knee replacement, we can balance ligaments degree by degree. During hip replacement, we can optimize acetabular (socket) placement, leg length, and offset.
When dealing with complex biological systems, there will always be factors beyond our control. Robotic total joint replacement is an amazing tool, which gives us tighter control over prosthetic implantation and soft tissue balance. This will improve the function and longevity of implants for patients.
Much of this website is directed toward proper rehabilitation after joint replacement. While prosthetic alignment and soft tissue balance will be improved using the Mako robot, appropriate rehabilitation will always be crucial to maximizing outcomes.
Total knee replacement has become a very common elective surgery, and patients are often amazed at how quickly they can get back to "normal" life after surgery. Within hours of their surgery, my patients are often able to begin walking with the assistance of a physical therapist and a walker. While most of my total joint replacement patients can be discharged to home within 48 hours, many are stable for discharge within 24 hours of surgery.
In spite of the anticipated rapid early recovery following total knee replacement, there is still a significant healing process that must occur. This healing process progresses through an inflammatory cascade and continues for over a year from surgery. It is this inflammatory cascade that requires a dedicated stretching regimen to ensure optimal knee range of motion following surgery.
Many patients are concerned that their knee feels warm, and may appear swollen and/or pink in the early post-operative period following knee replacement. In the vast majority of cases, this is normal and an anticipated part of the recovery period. Of course, if there is ever a concern, you should always discuss this with your orthopedic surgeon. Why does this happen? Basically, the body increases blood flow to the knee region to support the healing process. This increased blood flow results in the warmth, swelling and redness often experienced by the patient.
As the healing process progresses, the warmth, swelling and redness dissipate. The warmth can take 6 months or longer to resolve. Swelling and redness generally resolve within a few weeks of surgery.
A bone scan is a nuclear medicine radiological study that reveals bone metabolic activity. It will light up in areas that are irritated such as fractures, stress reactions, tumors and arthritic joints. If a bone scan is performed within 2 years of a total joint replacement, it will show increased bone metabolic activity adjacent to the relatively new prosthesis (even when the prosthesis is functioning properly). This is further indication that the healing process following joint replacement progresses over a very long period of time. Thankfully, the replaced joint usually feels great, long before the body has fully recovered.
So, after total knee replacement you can monitor the healing process by feeling the skin overlying your knee. As your skin gradually cools off, month-by-month, you know the healing process is winding down.
Please note: Severe swelling/redness, drainage from the wound, increasing pain, and/or loss of range-of-motion should not be assumed to be normal. If there is any concern, you need to be evaluated by your orthopedic surgeon immediately.
I previously discussed how important it is to regain full knee extension following total knee replacement. Full knee extension is required for a normal, low energy gait cycle. Anterior knee pain can occur for a variety of reasons, but lack of full knee extension (otherwise known as a knee flexion contracture) will overload the patellofemoral joint (knee cap and femur joint) causing pain. Unfortunately, regaining knee extension after total knee replacement is generally challenging and often uncomfortable. I previously discussed the basic stretches I commonly recommend. Today I demonstrate the prone hang technique. This method uses gravity and relaxation to gently and progressively induce full knee extension.
Here I am lying on my stomach. My left knee (closest to the viewer) is held slightly flexed. This demonstrates the appearance of a knee flexion contracture. Remaining in this position for long periods of time (a minimum of 10 minutes 6 times per day) will result in gradual correction of the flexion contracture. The longer you remain in this position the better. Ideally you would spend a half-hour or more in this position several times each day. A long duration, gentle stretch will allow the viscoelastic biologic tissues to elongate.
By placing my opposite foot on the back of my heel and relaxing, my left knee is pushed into a more extended position. In this case, my right leg provides additional weight, helping gravity force my left knee straight. This may be necessary for more resistant cases of knee flexion contracture.
This is the goal. Full, symmetric extension of both knees.
Here I have placed a sandbag on the back of my ankle to provide additional extension force to my left knee. An ankle weight would also work nicely. Remember, the goal is to relax and allow the soft tissues (posterior capsule) to progressive elongate. This takes time. I recommend spending at least 10 minutes in this position several times per day. Longer is better, and will result in faster gains. Remaining in this position for 30-60 minutes at a time is challenging but ideal.
Time and effort spent regaining full knee extension after total knee replacement will result in better knee function and reduced knee pain for the life of your knee replacement. As with all the stretching techniques I recommend, gentle, progressive, long-duration stretches. Cycling or bouncing the stretch is not necessary and probably irritating/counterproductive. Try to relax as much as possible during the stretch. Remember that some increased pain during and immediately after stretching is normal and expected.
The sooner you are able to regain full knee extension following total knee replacement the better you will feel, the easier your rehabilitation will be, and the more rapid the restoration of an efficient gait cycle.
Traditionally, orthopedic surgeons universally recommended patients with joint replacements take a dose of antibiotics prior to dental work. This practice was generally supported by the American Academy of Orthopedic Surgeons. Recently, this recommendation has come into question with the American Dental Association stating that routine use of antibiotic prophylaxis following total joint replacement is not necessary.
Why the controversy?
Simple. We do not have sufficient data to make a strong recommendation backed up by science. The incidence (regardless of cause) of total joint infection is quite low at around 1-2%. When a problem occurs very infrequently, testing an intervention requires an enormous study to show an effect. Such a study simply has not been done.
Let's look as some more data. While the bacteria implicated in the majority of total joint infections are staphylococcus species, which are mainly found on the skin, infections can also occur due to streptococcus species. The predominant bacteria in the mouth are streptococcus species. We know that bacteremia (bacteria present in the bloodstream) occurs during and after dental work. Whenever bacteria are present in the bloodstream, there is concern that they can be deposited on "at risk" material such as artificial heart valves and total joint replacement prostheses. The tendency for bacteria to be deposited is likely higher in areas of increased and/or turbulent blood flow. Dental bacteria have been isolated from tissues deep within the body. And documented total joint infections due to dental bacteria have indeed been reported. Even native (non-replaced) joints can become infected as a result of oral bacteria following dental work.
Although based mainly on a few case reports, my conclusion is that oral bacteria routinely enter the blood stream during dental work, and it is possible that a deep prosthetic joint infection can result.
So why the controversy? There are different perspectives.
First, orthopedic surgeons know that an infected total joint replacement is a big deal. It usually requires more surgery, sometimes multiple operations and long-term IV antibiotics to cure. A cure is not guaranteed, and even when cured, return to pain-free function is not guaranteed.
Second, dentists. Since there is not overwhelming evidence linking dental work to total joint infections I believe the issue has been minimized a bit by the dental community. I feel the American Dental Association has overstepped the science when stating antibiotic prophylaxis is not indicated prior to dental work. This conclusion was essentially based on a single case-control study. To make such a conclusion, a properly conducted, prospective randomized study on a huge population is required. Dentists do not directly see or have to take care of a total joint infection and therefore may under-estimate the magnitude of such a problem. Perhaps also distancing the dental field from orthopedic infections could be felt to minimize liability in such cases. Interestingly, most local dentists actually encourage prophylactic antibiotics in spite of the ADA recommendations.
Third, population health. Antibiotic overuse is not without consequence. There are multi-drug resistant bacteria that have evolved in part due to the tremendous volume of antibiotic medication used worldwide. (Of course the vast majority of antibiotic use is in veterinary medicine and food production, which is clearly a topic for another blog posting.)
Fourth, the total joint replacement patient. Antibiotics can be associated with negative side effects, allergic reactions, and secondary infections. So we need to carefully balance the risks and benefits. As I have outlined above, this is challenging because the risks and benefits have not been clearly defined scientifically.
Here is my approach. I recommend all of my total joint patients take a single dose of prophylactic antibiotics prior to dental work for a minimum of 2 years following surgery. 2 years is significant because we know there is increased bone metabolic activity (increased and turbulent blood-flow) around the total joint prosthesis during this time. If a standard-risk patient wants to use antibiotic prophylaxis in this way indefinitely, I would not deny them the antibiotics after carefully discussing with them the risks and benefits. I recommend any high-risk patient (immunocompromised, diabetic, cancer, rheumatoid arthritis, etc) take a single dose of prophylactic antibiotics prior to dental work forever.
With this approach, I am clearly biased in favor of my patients over the general population. In other words I feel that the single antibiotic dose I prescribe to my patients every six months is unlikely to have a major negative effect and also very unlikely to make a major contribution to worldwide bacterial resistance. Antibiotics are used in far greater quantities in the veterinary medicine and food industries, and are also inappropriately used in viral illnesses where they will have no benefit. Although prosthetic joint infection is rare at the population level, sparing an individual patient such a negative experience is a tremendous benefit.
When I eventually undergo a joint replacement, based on my current understanding of the issues, I plan on using prophylactic antibiotics forever.
When can I drive?
This is a very common question patients ask following surgery. Some studies have suggested that reaction time and/or braking force is reduced for weeks or even months following total knee replacement surgery. This could lead us to recommend that patients do not drive for a prolonged period of time following total knee replacement surgery. Logistically, this can be challenging.
A recent study showed that patients with osteoarthritis of the knee (without having undergone knee replacement surgery) had reduced driving ability based on diminished reaction time, movement time, and they ultimately had reduced braking performance. In spite of these findings, is not reasonable to tell patients with osteoarthritis of the knee that they can never drive.
A brand new article in the Journal of Arthroplasty shows that 80% of patients have regained their pre-surgery braking performance by 2 weeks following total knee replacement. All patients in this study were back to baseline by 4 weeks.
This reinforces my standard recommendation, but still leaves out one key issue. Pain medication. Narcotic pain medication is commonly used for several weeks following total knee replacement. This can impair driving skill and reaction time independent of knee surgery.
My recommendation to patients after total knee replacement surgery is that they should not drive while they are using narcotic medications. Furthermore, they should not drive until they feel comfortable doing so. This time period is patient specific, and there is a wide range. Common sense should prevail. I believe patients generally know themselves, and certainly do not want to place anyone at risk by driving prematurely.
I recommend patients focus as much as possible on rehabilitating their new total knee replacement for the first few weeks, limiting their driving to the essentials: food shopping, physical therapy, and follow-up with their orthopedic surgeon. Soon, their pain level will be down, and their confidence to drive will return.
We can then add driving to the list of lifestyle improvements made possible by total knee replacement.
As always...please discuss specific recommendations with your surgeon.
Non-operative treatment for osteoarthritis includes activity modification (do less, reduce impact, reduce load, reduce distance, etc), topical medications, oral medications, bracing, and injections.
A common injection used in orthopedic clinics many times each day is generically referred to as "cortisone." It is a combination of a local anesthetic (like the dentist uses) and a steroid. There are a variety of local anesthetic agents used (lidocaine, bupivacaine, etc.), and a variety of concentrations available. Additionally, there are a variety of steroids that can be used. Each surgeon likely has a preferred combination.
Just a side-note: the steroids orthopedic surgeons inject for anti-inflammatory purposes are completely different from the anabolic steroids associated with body-building. They will not make you grow muscle.
Although not everybody responds the same, a cortisone injection often provides rapid and significant relief from arthritis pain. This relief can last for months. When the pain returns, we have a discussion regarding the amount and duration of relief experienced. I generally allow my patients to undergo up to 3 cortisone injections per joint, per year.
Some patients aggressively pursue these injections and would accept them much more frequently than I recommend. Others prefer to avoid them entirely. Reasons for this vary. Some patients are simply afraid of the needle. This is a shame, because most patients report only mild discomfort when I've performed a cortisone injection. Other patients are more concerned about the potential detrimental effects. They've heard that cortisone destroys cartilage and will hasten their joint deterioration.
Some in vitro (test tube) and animal studies have shown chondrocyte (cartilage cell) toxicity due to local anesthetics, steroids, and combinations of both. Cartilage cell damage in a test tube does not necessarily mean that an injection into a living human's joint will create similar damage. In fact, another study in which samples of living cartilage were taken after the knee was injected with local anesthetic showed no such effect. While I certainly understand that cells in culture may be negatively effected, I have seen no clinical evidence of joint destruction due to cortisone.
I think it is reasonable to assume, like with most medications, that while there is a benefit, there is also some potential for harm. The key is to use cortisone, like all medications, judiciously. That is, only when indicated, not too often, and at the lowest effective dose.
It is important to remember that we are using cortisone in joints that are already moderately to severely damaged due to arthritis. The joint is already irreversibly damaged due to the cumulative effects of gravity, activity, and time. A cortisone injection can provide a significant improvement in quality of life and can potentially delay surgery. A recent article in the Journal of the American Academy of Orthopedic Surgeons confirms the efficacy of cortisone injections to provide pain relief for osteoarthritis.
Remember, a total joint replacement involves removing ALL of the cartilage from the joint. I would argue that that is much more toxic to the cartilage than a few cortisone injections.
I am not suggesting people should not have their joints replaced when they wear out. The majority of my practice involves replacing destroyed knees, hips, and shoulders. These operations predictably alleviate pain and restore function. Total knee, total hip, and total shoulder replacements, help hundreds of thousands of patients every year in the U.S.
I am suggesting that appropriate use of cortisone can allow some patients to delay an operation, sometimes for years. And if there is a risk that microscopic cartilage damage occurs, the ability to reduce pain and delay surgery is worth it.
Although playing tennis can result in tennis elbow, most cases of tennis elbow, also known as lateral epicondylitis, are actually due to overuse when working with the hands. A tendon is the tissue that attaches muscle to bone. The suffix "itis" means inflammation, and while acute overuse injury can cause inflammation, the typical case of tennis elbow is more chronic, due to repeated overuse, and results in degeneration of the tissue. This situation is more appropriately called "tendinosis."
The pointy bone that sticks out on the outside of the elbow is called the lateral epicondyle. This is the common origin of the wrist extensor muscles which cross the elbow and then cross the wrist. It is this tendon that is injured with tennis elbow.
So, when attempting to grip something firmly, the wrist extensor muscles (that attach to the outside of the elbow called the lateral epicondyle) contract firmly. This is fine. Now when elbow range of motion is added simultaneously, the wrist extensor muscles experience shearing, or variation in the force they experience, while the elbow moves. Additional irritation like a short rapid wrist flexion force can sometimes occur. This combination of forces can create trauma to the extensor muscle group at its insertion point on the lateral elbow (lateral epicondyle).
A perfect example of the above scenario is when the tennis ball makes contact with the racket during a backhand swing, hence the name tennis elbow.
A more common situation in my practice would be swinging a hammer all day, scraping paint, or pulling weeds. Basically power grip with the hand superimposed on simultaneous wrist and elbow range of motion.
Acutely, micro-tears can occur in the muscle origin on the outside of the elbow (lateral epicondyle). This can create pain and inflammation. When allowed to rest and recover, the issue resolves. However when the overuse occurs repeatedly, and the micro-tears are not allowed to fully resolve prior to additional trauma, the condition can become chronic. The normal tendon tissue (a tendon is the tissue that attaches muscle to bone) breaks down, and the tissue becomes disorganized and weak (tendinosis).
Lets talk about treatment. It is important to know that proper non-operative treatment will cure 90% of people. Unfortunately, especially in chronic cases, it can take months to resolve.
Also known as patellofemoral syndrome, anterior knee pain can be extremely frustrating for patients and surgeons alike. Anterior knee pain is extremely common and can have a variety of causes. Patellofemoral arthritis (knee-cap arthritis), and knee-cap dislocation (patellofemoral instability) are two diagnoses that can cause anterior knee pain, but they each will require a separate blog posting of their own.
Patients experiencing patellofemoral syndrome complain of aching pain in the front of the knee which can range in severity from mild to intense. It is often made worse by sitting with the knee bent for a prolonged period (movie theater or back seat of car). In this situation the pain can be improved by extending the knee (straightening it). Climbing or descending stairs can also be quite irritating.
This condition affects people of all ages and of all fitness and activity levels. I have diagnosed and treated this condition in marathon runners, adolescents, and patients who previously underwent total knee replacement. Usually the problem gradually worsened and has been present for a fairly long time when it gets to me. The key to the diagnosis is to listen to the patient. The history given tends to be very consistent.
To better understand this condition, let's start with some background information.
The patella (knee-cap) is subjected to the greatest force of any cartilage in the body (3-5 times body weight during normal activity and up to 10 times body weight when jumping). It is embedded within the extensor mechanism of the knee so that it can provide leverage to the quadriceps muscle group. The front of the knee is richly innervated and is thus very sensitive to abnormal pressures. The position of the femur (thigh bone) during activity will change the amount and distribution of forces on the patella.
There is a very consistent examination finding associated with this diagnosis. Patients usually will have very weak hip flexors (muscles than bring the thigh forward relative to the torso) and hip abductors (muscles that bring the thigh away from the midline). Usually the hip external rotators will also be affected.
What does the hip have to do with the knee-cap?
The hip flexors and abductors are very important during the gait cycle (walking). The abductors must contract with great force to keep the pelvis level during single leg stance. The hip muscles together act as the "foundation" for your leg. If they are weak, your leg will be poorly controlled when walking. This can result in abnormal gait mechanics, abnormal rotation of the femur when weight bearing, and abnormal patellofemoral mechanics.
This combination of issues multiplied over thousands of steps each day can result in anterior knee pain.
Ok, so how do we fix it?
My recommendation is to focus on the hip. Strengthening the weak hip muscles will almost always result in a cure. Unfortunately, this can sometimes takes weeks or months. Remember, we are rebuilding muscles that have gotten deconditioned over a long period of time. This takes time. Knee pain gradually resolves as hip strength gradually improves. The exercises I recommend are very simple:
Keep your knee locked in extension. Raise your leg from your hip keeping your toes pointing toward ceiling. Up and down counts as one repetition. Aim for a set of 30 repetitions. Then add sets.
It is important to do these exercises on both sides, even if only one knee hurts. You want to keep things balanced.
Lateral raise. This exercise focuses on the hip abductor muscles. Lying on your side, slowly elevate the leg from your hip, keeping your knee straight and your toes pointing forward (not toward the ceiling). You should feel the burn on the side of your butt.
So, that's basically it. Remember, we are building hip muscles. It takes time. I recommend doing these exercises on both sides (even if only one knee is painful) so everything stays balanced. Each repetition should be done slowly when raising and lowering. You may be surprised by how challenging this set of hip exercises can be. You should work up to 3 sets of 30 repetitions for each muscle group. Repeat the workout twice per week. The total work-out should only take about 15 minutes. Resist the urge to do these exercises more frequently. The purpose of exercise is to stimulate the muscle to grow. It then needs to be allowed to grow, and this takes time. Stimulating the muscles with resistance exercise too frequently will be counter-productive.
When doing this exercise becomes easy, feel free to add some additional resistance. You can wear a boot, or use an ankle weight.
It is a common misconception that one should exercise the quadriceps using a leg extension machine. This is a mistake and I would strongly suggest avoiding any knee isolation exercises in general, but when dealing with patellofemoral syndrome in particular. The knee extension machine will worsen anterior knee pain.
Be patient, and consistent with these exercises. As your hip strength improves, your knee pain will improve as well.
In a previous post, I described what I feel to be the most important shoulder stretch. It is very important functionally to be able to reach out in front of you, and to reach overhead. While my focus in the prior post was frozen shoulder (otherwise known as adhesive capsulitis), the stretch I described is very useful for regaining function after rotator cuff surgery, shoulder labral repair surgery, and trauma. The anterior and inferior (front and bottom) shoulder capsule/ligaments are stretched using this technique.
(Please note: If you are dealing with a frozen shoulder, this stretch may be too irritating to begin with. I recommend you begin with anterior, inferior capsule stretching using the best stretch for a frozen shoulder. You can come back here once you have regained the ability to raise your arm over your head again.)
Sometimes, in spite of having done an outstanding job rehabilitating their shoulder following surgery, a patient may have some residual pain. Another common subset of patients presents with shoulder impingement syndrome or bursitis. These patients report pain which is usually lateral arm pain, aching in character, and may be worse at night. If forward elevation (reaching overhead), and abduction (reaching out to the side) are near normal, and rotator cuff strength is good, it is important to focus on the posterior capsule (ligaments in the back of the shoulder).
A tight posterior capsule can cause abnormal shoulder mechanics. This can cause the shoulder ball (humeral head) to translate superiorly (upward) when raising the arm instead of rotating in the socket (glenoid). This pinches the rotator cuff and causes pain. The rotator cuff normally pushes down on the humeral head during rotation, but when it is irritated it will get lazy. Unfortunately, this compounds the problem, and allows the humeral head to further translate upward during activities. A cycle is then created whereby the problem gets progressively worse.
We need to break this cycle.
When I find the posterior capsule to be tight, I recommend using the sleeper stretch. This is a simple stretch that a patient can do on their own. As always, I recommend stretching every day, with no days off. I also recommend gentle progressive static stretching. That is, slowly applied pressure that is then held at the endpoint for relatively long duration. This means minutes rather than seconds. We are taking advantage of the viscoelastic nature of our soft tissues. The posterior capsule tends to be relatively thin tissue, and thus, this stretch does not require high force.
In these photos I am lying on my side. For this demonstration we will assume my right shoulder is the bad one. So, I am lying on the bad side. My elbow is out in front of me. The upper arm should be even with the shoulder. Both palms are facing toward my feet. Now gently and progressively apply force with the left hand. The goal should be to create rotation of the right palm toward the floor.
This should create tension and stretching pain in the back of the shoulder.
Ordinarily I would recommend resting your head on a pillow for comfort. I am not doing this to avoid obscuring the positioning.
Here is the view from above. Again note my upper arm is at shoulder level and my palms are facing toward my feet.
Pressure is applied rotating my right shoulder internally, and pushing palms toward the floor.
Here is a less aggressive position. It may be good to begin this way.
You can place a pillow behind your back to lean against. For all of these positions, resting your head on a pillow will allow more relaxation and thus a more pleasant stretch that you can hold for a longer time period.
This is the most aggressive sleeper stretch position. This will concentrate more force on the posterior capsule. It may not always be necessary to regain balance. I recommend testing each of this positions on the other (good) side so you have a benchmark to assess what is normal for you.
Some key points:
How much motion should you have at any given point after surgery? Of course, you should speak to your surgeon about the specifics of your case. However I'd like to provide some general guidance on this subject.
During knee replacement surgery, the knee will be reconstructed using a metal and plastic prosthesis, and the ligaments balanced. At the conclusion of the operation, the knee will be able to fully extend (straighten) and fully flex (bend back). After surgery, although initially pain will prevent full range of motion, scar tissue has not had a chance to form. Most patients are able to move from full extension (0 degrees) to 90 degrees (foot flat on floor while sitting in normal chair) within 24-48 hours.
It is not uncommon for patients to lose a bit of motion around 7-10 days from surgery. This is a result of increased pain and swelling due to the inflammatory cascade. This inflammation peaks around 10 days from surgery. It is ok to go a bit easy on yourself during this time. Use plenty of ice and anti-inflammatory medication if it is allowed by your surgeon. But keep stretching. Do not allow yourself to lose full extension. This is crucial.
By the first postoperative visit around 2 weeks from surgery I would like to see a minimum of 0-90 degrees of motion.
By 6 weeks from surgery I would like to see 0-120 degrees minimum.
Patients may gain an additional 5-10 degrees of deep flexion over the course of the first year following surgery if they've gotten to 120 degrees by 6 weeks.
If these parameters are not met, other options are available. I begin asking patients to follow-up with me every other week or more to track their progress, to answer questions, and provide motivation and support. I understand that this process isn't always easy and is never fun. If inadequate range of motion isn't achieved by 6 weeks, I then recommend manipulation under anesthesia to break up scar tissue that has been allowed to form. This buys us some time and generally gets things back on track.
In an earlier post, I described my experience with a frozen shoulder. Here are some pictures showing exactly how I rehabilitated myself and how I recommend my patients stretch on a daily basis.
The initial position will look something like this. I am using a jar of sauce to provide some downward pressure. My good arm is placed in a similar position and allowed to rest with the shoulder, elbow, and wrist touching the floor. When your bad shoulder is hurting from the stretch, look over at your good shoulder and remind yourself what normal range of motion looks like.
This is the goal. Now I am able to touch my shoulder, elbow, and wrist to the floor at the same time.
You will not get to this point quickly. It will likely take hours of stretching like this over weeks to go from the first picture to this one.
Here is how it looks from above.
Gradually bringing your hand and elbow closer to your head will add additional stretch.
Some key points:
Uncommonly, a patient is unable to regain adequate range of motion in a reasonable period of time following total knee replacement surgery. When I observe a patient gradually falling behind with rehabilitation, I begin following them in my office more closely to provide guidance, and motivation. This can be a very frustrating situation for both the patient and surgeon.
I have previously written about the tissue planes in the knee that need to be encouraged to glide, and on some stretching techniques to accomplish this. My recommendations are based in part on the viscoelastic nature of these tissues.
I believe the quadriceps muscle can sometimes thwart a patients efforts to regain flexion. In the years prior to making the decision to proceed with knee replacement, a patient likely experienced episodes of giving-way or jolts of pain. The quadriceps would need to contract aggressively to prevent the knee from buckling. Additionally, many patients develop an abnormal, stiff-legged gait pattern which likely minimizes joint motion and pain. This quadriceps activity is likely subconscious, but by being repeated over a long period of time create neural pathways in the brain that are hard to break.
Postoperatively, the habitual quadriceps contraction in response to pain may make rehabilitation more challenging for these patients. I have developed this idea after hearing many patients explain how hard their physical therapist is pushing on their knee, and it simply will not bend. Ive been told the physical therapist is actually off the ground being supported by the patients knee. It sounds horrible. The only way for this to be possible within the first 6 weeks or so from surgery is for the patients quadriceps to be pushing back.
How can I be so certain? Because of my experience with manipulation under anesthesia. At around 6 weeks from surgery if a patient and I agree that their range of motion is not acceptable I perform this procedure.
A patient is briefly placed under anesthesia. I gently flex the knee while flexing the hip. Pressure is then progressively applied through the tibia and soft tissue releasing is felt and sometimes heard while this occurs. The goal is to re-establish the pre-patellar tissue plane (between the skin and the kneecap) and the suprapatellar pouch (between the quadriceps tendon and the femur).
Once this has been accomplished the knee will generally flex to 120-130 degrees under the force of gravity alone. This verifies that no more joint adhesions are obstructing motion.
So again, how do I know the quadriceps is fighting back? Because it only requires me to apply gentle pressure. Maybe 5-10 pounds of force. Worst case 20 pounds or so.
Based on this I recommend focusing on relaxing the quadriceps while stretching. Additionally, consider pre-fatiguing them. This is a technique where you would attempt to extend your knee while blocking it from moving (isometric quadriceps contraction) Then relax the quad and enter directly into the stretch. This can create significant gains. My experience has been most positive with prolonged, low force stretching as opposed to shorter, more aggressive stretches.
Relatively early manipulation of a stiff knee when necessary helps the vast majority of patients get back on track. By breaking up immature scar tissue it extends the rehabilitation window a bit. Patients still need to work hard on their stretching exercises on a daily basis, but by using this technique we can "catch them up," and help to ensure adequate function and pain relief.
It is very common for a patient to bring a friend or family member along to their office visit with me. I think this is generally a good thing, as we cover a lot of information in a brief period of time. Studies have shown that patients recall only a small fraction of what was discussed with their doctor. Perhaps a second set of ears can improve this a bit.
Some of the more complicated discussions I have with patients concern the decision to proceed with surgery. It is important that patients have reasonable outcome expectations and understand the potential risks involved and the need to commit to thorough and careful rehabilitation.
As most of my surgery is elective, at some point the patient must chose to proceed surgically. For elective operations, there is never a "need" or requirement for surgery. It is a lifestyle choice. Each patient has their own risk/benefit analysis. I view my role is to educate regarding the procedure and possible risks, to present all non-operative options, and to make some predictions about potential outcomes based on the patients medical history, and particular problem.
When dealing with a chronic progressive problem like osteoarthritis of the knee, patients have usually tried a variety of non-operative treatment options prior to considering surgery. Even when non-operative treatment has failed to adequately control symptoms, patients don't always know if they should proceed surgically. While working through this discussion, I commonly find the 3rd party often suggesting the patient proceed surgically. I do not talk people into elective procedures. And I will often address the 3rd party's comment with a statement of my own: "it's very easy to sign someone else up for surgery."
The odds are dramatically in the patients favor when considering most orthopedic procedures. We can reliably achieve meaningful improvements in quality of life. The vast majority of patients, once rehabilitated, tell me they waited too long to proceed surgically. Nevertheless, the point that a patient decides to have surgery is a major turning point in their life.
If a patient does not appear convinced that surgery is appropriate, I suggest they not make the decision in the office with me in front of them. I recommend that they go home and think things over, to determine if their quality of life is acceptable as-is. A patient should never feel pressured into undergoing a elective operation. We can always do surgery, but we can never take it away. I think patients intuitively understand this, and often the third party does not.
Patients can easily decide to proceed with elective orthopedic surgery when the time is right. The threshold in a particular patient is unique, and is based on countless factors including pain, desired activity level, past experiences, support system, finances, work requirements, etc.
The psychology of recovery after orthopedic surgery is extremely important, and I feel under-appreciated. A future post will address the psychology of healing.
For now, I will suggest that an excellent surgical outcome begins with positive feelings about the decision to proceed with surgery. When a patient feels it is the right time in their life, that they have exhausted alternatives, that they have a surgeon they can trust, and that they have an optimal support team, the stage has been set for a positive result.
Total knee replacement surgery is an effective way to relieve arthritis pain when non-operative measures have failed. A substantial portion of the outcome, however, is based on adequately rehabilitating after surgery. The most important part of the rehabilitation program is regaining normal range of motion.
This is easier said than done.
At the time of a properly performed knee replacement surgery, the soft tissues are balanced and the range of motion should be full. That is: all the way straight, to all the way bent. This is something we test during surgery. Then the incision is closed and the healing process begins. Initially, there could be some swelling and acute surgical pain from the incision/surgical approach. Soon this acute pain subsides and stiffness begins. The stiffness is experienced by many patients as pain, especially when moving against the endpoint.
In a prior posting I discussed the tissue planes that need to glide to allow proper motion. Each day that passes after knee replacement surgery, more healing occurs. This process can create connections, or adhesions, between these tissues. After about 6 weeks, enough scar tissue has formed, that most patients are unable to obtain more range of motion by stretching. In other words, at around 6 weeks from surgery no more progress with regard to range of motion is possible.
The trouble is, in order to regain excellent function, adequate knee range of motion is necessary. Most patients are anxious to walk, ride a stationary bike, and are often quite focused on regaining strength. While these are fine things to do, and I certainly understand this desire, redirecting the focus to stretching appropriately remains my priority during the first 6 weeks postoperatively. Once range of motion is reestablished, all of these activities will be possible. Because we have a limited time to regain this range of motion this needs to be the priority early on.
Thankfully these stretches are simple. Gently and progressively force the knee straight. And then gently and progressively force the knee bent. Simple! Except when it's not.
Sometimes, and fortunately it is rare, a patient really struggles to regain range of motion after their total knee replacement. This can be a very frustrating situation for the patient and surgeon alike.
I recommend stretching early, often, gently, but progressively. It is better to regain motion early than to attempt to catch up when stiffness is setting in.
The simplest stretches are shown below:
This is one of the easiest stretches for extension. Place your ankle on a pillow. Relax your muscles to allow your knee to sag down. Then attempt to push the back of your knee down. This is a side view of my knee. It is important to note that my kneecap and toes are pointing straight up. This stretch can be held for minutes, gradually relax your muscles more and more, allow gravity to do the work. The longer the stretch the more the viscoelastic tissues will elongate.
This is the wrong way to stretch. This is a view of my knee from above. There is a natural tendency to externally rotate as your hips relax. Our goals are not being accomplished if this is allowed to happen. If you find this happening, simply place additional pillows or folded blankets along the outside of your foot and thigh to hold your toes and kneecap pointing up.
Now we are working on regaining flexion. In this example we are working on gaining flexion in my right knee (in the back ground of this photo). Here I have placed my left leg in front of my right ankle. I am using my left leg to help bend my stiff right knee more. This works best when done progressively over a period of minutes as opposed to seconds. Use your hamstrings in both legs to try to flex both knees further.
For deeper flexion than the previous stretch, this position utilizes a step-stool to provide deeper knee flexion. As shown, leaning forward and applying pressure with your hands can increase the stretch.
This is a stretch that can achieve extreme flexion. This time I am lying on my back. My knee is pointing up toward the ceiling. Flexing the hip relaxes the quadriceps. The hands are used to to pull the leg toward your body. The effect is increased hip and knee flexion.
Please note: if you have a total hip replacement, be very careful with this position as it can produce significant hip flexion.
These stretching positions should take care of 90% of total knee replacement patients. These stretches should be done everyday, ideally multiple times per day, with no days off. The longer the stretches can be held, the better. Remember to relax as much as possible while stretching and remember that a little pain is normal an expected. If no pain is encountered, I would recommend pushing a little bit harder. As always, if you have any specific questions about your particular case, discuss with your surgeon.
Occasionally we encounter a patient that has a very difficult time regaining motion. I have a few additional recommendations in these cases and will address that situation in an upcoming posting.
I began playing ice hockey when I was 7 years old. When I was an orthopedic resident in New York City we formed a Hospital for Joint Diseases orthopedic hockey team. We had the unique opportunity to play outside in central park and also at Chelsea Piers with a view of the Hudson river and the New York skyline.
In spite of the violent reputation ice hockey has, I never personally sustained any significant injury. Until one evening around midnight (we had terrible ice times) when I was involved in a collision deep in my defensive zone. The back of my left shoulder made contact with the boards and I felt a zing of pain into the side of my arm. I immediately had difficulty raising my arm. Thankfully, it was toward the end of the game.
I liberally applied ice when I got home, but when I woke up in the morning, I still couldn't actively raise my arm. I was fairly certain my injury was a rotator cuff contusion, and not a rotator cuff tear due to the mechanism of injury, and therefore would be self-limited. This proved to be correct, and by that afternoon, my active range of motion had returned, albeit with some pain.
Confident my pain would improve as the contusion healed, I went about my normal daily activities for the next several weeks. I grew somewhat concerned however when the pain wasn't decreasing, but rather it was increasing.
As a physician, working with world-renowned orthopedic surgeons who would be happy to assist me, I instead chose to ignore it. My life was too busy to deal with my shoulder. I could work, and for the most part I could compartmentalize the pain.
Working at shoulder level or below was essentially normal and pain-free. But, if I forgot and suddenly reached for something, a knife-like jab brought my shoulder's issues front and center. After several months went by, I began to feel that my first choice of treatment (doing nothing) had failed.
I finally examined my shoulder objectively and noted that although my strength was normal, I had lost some range of motion. More interestingly, I had lost not only active range of motion, but passive range of motion as well. At this instant I understood why my pain wasn't getting better. I had developed a frozen shoulder. Now everything made sense.
At this point, I began my rehabilitation program. Everyday after work I applied ice to my shoulder for about 20 minutes. I purchased an ice machine to assist with this. I tried traditional stretching techniques, but was disappointed with the results. I was able to achieve intense pain, but absolutely no increase in range of motion. I actually felt I was getting worse. Frustration is an understatement.
A possible treatment for a frozen shoulder that has been resistant to all nonoperative measures is a manipulation under anesthesia. The surgeon essentially forces the joint through a range of motion, tearing the tight tissues. This is something I clearly hoped to avoid.
I recognized that biologic tissues are viscoelastic. I felt that based on this characteristic a stretch done gently, but for longer duration could be more effective. And so I began stretching differently. I measured the duration of stretch in minutes as opposed to seconds. I got to the painful endpoint and held it under tension for as long as I could tolerate it. Knowing that the longer I stretched the better it would be I increased the duration of my stretching to 30 minutes or more. Stretching hurts. I reminded myself that in spite of the pain I was experiencing, I was not creating damage.
To maintain a stretch of this duration requires you to relax. The best position for me was to lay on the floor on my back and attempt to simultaneously touch my shoulder, elbow and wrist to the floor at the same time. I added some weight to my hand to increase the stretch and watched TV.
I did this routine every day. At first I wasn't sure it was helping. But then I instinctively reached for something without thinking. Something that had previously caused a jolt of pain. And I felt no pain at all. This motivated me to add weight and time to the stretching program. Within a few more weeks my shoulder pain had resolved and I had regained normal range of motion.
This method has made surgery for frozen shoulder very rare in my practice.
When I first describe this technique to my patients, they seem incredulous. Most have already been through a course of physical therapy and are very frustrated. They presented to me to have an operation. But with very few exceptions (sometimes patients with diabetes have very resistant frozen shoulders), the vast majority of patients can avoid the operating room using this method.
I will upload some pictures of how I recommend stretching in an upcoming post.
Biologic tissues are viscoelastic. That means their stretchiness changes depending on how hard they are stretched. We can take advantage of this characteristic when we are rehabilitating a stiff joint. This becomes very important with certain medical problems. Specifically: total knee replacement and frozen shoulder. This concept is generally helpful in orthopedic rehabilitation and I take advantage of it whenever applicable.
Think of silly putty. When slowly stretched it can be drawn out into a long strand, but when pulled aggressively it will snap and break in two. This is an extreme example of viscoelasticity.
Your tissues are similar. While extreme force stretching can cause tissue to tear, this is generally far beyond any amount of stretching a patient can do, even with a physical therapist. A manipulation under anesthesia is a maneuver performed by a surgeon to rapidly regain motion in a particular joint that has become stiff. Tissues tear, and inflammation results. This is the most extreme example of a high force, low duration stretch. It is best to avoid this type of intervention if possible. It is preferable for a patient to spend the time necessary to recover joint range of motion using a long duration, low force stretch. It will result in less inflammation and less pain.
Shoulders and knees commonly become stiff. Total knee rehabilitation requires stretching to regain range of motion after surgery. Stretching is required to speed up the recovery of a frozen shoulder. When attempting to regain range of motion patients are often told to stretch for 10-15 seconds and then relax. Over and over. Sometimes this is effective. Sometimes it is not. There is significant genetic variation with regard to tissue strength and inflammatory response, and significant psychological variation with regard to pain tolerance, and ability to relax while stretching. When a patient has trouble regaining range of motion I try to focus them on long duration, low force stretching. This tends to create less inflammation and is more likely to allow a patient to relax the muscles while stretching. Relaxing is very important because any muscle resistance will prevent gains in range of motion.
This sketch depicts how I think about stretching. A high force, brief stretch is more likely to cause inflammation. A gentle prolonged stretch is less likely to create an inflammatory response. The "amount of stretch" or the total area under the curve depicted by the hash marks could be identical, but my experience suggests the long duration, low force stretching will give a superior result.
How do I know this?
When I was a resident, I developed a frozen shoulder and used long duration, low force stretching to cure myself. I have subsequently recommended this technique to countless patients who presented with frozen shoulders that had failed to improve after many weeks of standard physical therapy. Although occasionally surgical intervention was necessary, the vast majority progressed using this technique and never needed surgery. This technique has become my standard recommendation following total knee replacement and to rehabilitate a frozen shoulder, and has minimized the need for manipulation.
Orthopedic Surgeon focused on the entire patient, not just a single joint.