The menisci of the knee are two crescentic shaped cartilages found within the knee, situated between the ends of the femur and the tibia. There are two menisci in each knee; the medial meniscus and the lateral meniscus. They are wedge-shaped in cross-section and are made of elastic fibrocartilage, not too dissimilar to the outer part of the ear – almost like two potato wedges sandwiched between the bones.

Image showing a view of the top of the shin bone as seen from above (bottom of image = front of knee)

Same view of the top of the shin bone (the tibial plateau) with the menisci shown.

What is the role of the menisci?

In the past it was thought that the menisci were just the vestigial remnants of a muscle within the knee, and they were routinely excised completely in the presence of any kind of damage. There are still many patients around today with nice big scars on their knees, courtesy of previous open total meniscectomies. However, it is now recognised that the menisci have a number of very important functions within the knee:

• they act as shock absorbers
• they share load within the knee
• they are secondary stabilisers, of particular importance in the ACL-deficient knee
• they probably contribute to proprioception (sensory feedback and reflexes) within the knee
• they probably have a role lubrication of the joint, and they may play a part in nutrition of the articular cartilage

Image showing the knee with the menisci intact. As the curved end of the femur pushes down on the flat upper surface of the tibia with weight-bearing, the menisci act as shock absorbers and cushions between the bones, helping to share the weight and dissipate the forces.

…and with a meniscus removed: the curved femur sits on the flat tibia and there is point-loading, with a greatly reduced contact surface area and significantly increased contact pressures. These increased pressures cause damage to the articular cartilage covering the surfaces of the bones, and leads to wear and tear and arthritis.

How do meniscal tears occur?

Meniscal tears are the most common injury of the knee presenting to an Orthopaedic Surgeon. In younger patients, meniscal tears normally occur as a result of sports injuries, with the most common mechanism involving twisting on a loaded flexed knee with the knee then giving way. Typically, the giving way is then followed by pain and swelling in the knee. The most common sports associated with knee injuries of this kind are:

• football
• netball
• skiing

With age, the menisci degenerate and become less elastic, more friable and more liable to tearing. Degenerate meniscal tears may occur spontaneously, with no specific history of any one particular traumatic episode. Alternatively, degenerate meniscal tears may occur from simple movements such as squatting or getting up from kneeling.

What are the symptoms?

The typical symptoms of a meniscal tear are:

• knee pain – this may be felt either at the front or the back of the knee
• giving way – this is normally associated with episodes of sudden pain
• swelling – this may be permanent or may occur after episodes of giving way
• locking – this is where the knee gets stuck and cannot straighten fully.

A patient with a meniscal tear may not necessarily experience all of these symptoms, but can have any combination of the above.

How is the knee investigated?

If there are clinical signs of arthritis within the knee, then the appropriate investigation is to simply perform an X-ray.

In patients where the history and clinical examination are strongly suggestive of a meniscal tear, then the clinical diagnostic accuracy for determining meniscal tears without the need for any special investigations is approximately 90%, in the hands of an appropriately trained, qualified and experienced Orthopaedic Surgeon.

In patients where there may be doubt regarding the diagnosis, where there is a suspicion of potential alternative pathology or in cases where there has been major damage to the knee and where there may be multiple concomitant injuries such as ligament tears, then an MRI scan of the knee may be indicated.

MRI scans do give quite interesting and useful pictures of the knee. However, they are not 100% reliable, as the diagnostic accuracy of an MRI scan for a meniscal tear is only approximately 80 – 90%.

MRI scan showing a side-on view of the knee with a tear in the posterior horn of the lateral meniscus (shown by red arrow) – the meniscus should show up as a solid dark triangular wedge.

What is the treatment?

Some patients respond well to conservative treatment with rest, alteration of activities and physiotherapy. However, the menisci of the knee have very poor blood supplies and therefore they frequently fail to heal up. Despite this, if a patient’s symptoms are only relatively minor then potentially no further specific treatment may be required.

However, in those patients with significant ongoing symptoms, surgical treatment is indicated. Surgery is particularly indicated if a knee is repeatedly giving way, as each time the knee gives way there is the potential for further damage to be being caused. The surgical treatment of choice is to perform an arthroscopy of the knee (keyhole surgery). This is a relatively minor operation, performed under a general anaesthetic and normally lasting somewhere in the region of approximately half an hour.

Intra-operative arthroscopic view of the inside of a knee with a radial tear of a meniscus (shown by red arrow).

In approximately 25% of younger patients, where a meniscal tear is found to be relatively simple, fresh and in the region of the cartilage around its outer edge where the blood supply is reasonable, it may be possible to perform meniscal repair using tiny devices comprising of anchors and sutures.

However, in the remaining 75% of younger patients plus in all those patients with ragged degenerate tears, the only appropriate option is to excise the torn tissue and trim the meniscus, which is known as a partial meniscectomy.

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What is tendonitis?

A not uncommon cause of pain around the knee is tendonitis. Tendonitis means ‘inflammation of a tendon’. This may occur after trauma, due to repetitive overuse or it can come on spontaneously.

Examples of some specific common tendinopathies around the knee include:

• Patellar tendonitis
• Quadriceps tendonitis
• Iliotibial band friction syndrome

Typically, pain from tendonitis is localisable to one specific point or area and is a burning pain that is aggravated by exercise.

Tendinosis is the condition where there has been chronic tendonitis or long term wear and tear in a tendon, and the tissue has become thickened, degenerate and scarred. The scarring can form a barrier preventing in-growth of blood vessels. This diminishes the blood supply to the tissue, inhibiting the healing process and exacerbating the tendinosis.

Most cases of tendonitis can be treated well with:

• Anti-inflammatories
• Rest
• Modification of activities
• Splinting
• Physiotherapy
• Steroid injections (for inflammation of the tendon sheath – tenosynovitis – but steroids should NOT be injected directly into tendon tissue itself, as this can cause rupture of the tendon.

For those cases where the symptoms are severe or where previous attempts at conservative management have failed, surgical treatment may become necessary.

The basic principles of surgery for tendonitis are to:

• Address any underlying causative factors, eg a bony spur that may be rubbing against the tendon
• Excise any severely degenerate tissue
• Open up the tendon tissue to encourage healing through in-growth of new blood vessels.

Patellar tendonitis

MRI scan (side-on view) of a knee with patellar tendonitis. The tendon should be dark throughout its length. At the top of the tendon, just below the patella, there is a pale area in the tendon, caused by inflammation and swelling.

Inflammation of the patellar tendon usually occurs in the proximal (upper) part of the tendon, near its insertion where it attaches to the inferior (lower) pole of the patella (kneecap). It is sometimes referred to a “Jumper’s Knee”. This condition causes pain at the front of the knee, just below the kneecap, which is often worse when the knee is flexed. In particular, it may be painful for the sufferer to kneel, sit for long periods, squat or go up / down stairs.

The diagnosis of patellar tendonitis can normally be made clinically. However, it can sometimes be difficult to differentiate clearly between patellar tendonitis and pain coming from the actual patella itself (eg chondromalacia or osteoarthritis). The diagnosis can normally be confirmed clearly by MRI or ultrasound scanning.

Intra-operative view of a patellar tendon showing patellar tendonitis plus degeneration of the tendon.

Persistent symptoms from patellar tendonitis that has failed to respond to other conservative measures may require surgical tendon decompression. This requires a small open surgical procedure whereby an incision is made at the front of the knee and the central inflamed portion of the tendon is excised. At the same time, it is sometimes felt appropriate to perform a knee arthroscopy at the same time as the tendon decompression, if it is deemed necessary to try and exclude other potential active pathology within the knee.

Often, patellar tendonitis occurs secondary to patellar tendon impingement, where a small spur of bone from the inferior (lower) pole of the patella rubs against the back of the patellar tendon when the knee flexes. The diagnosis of patellar impingement can normally be seen at ultrasound scanning or otherwise usually is clear on MRI.

In cases of patellar tendon impingement that require surgery, in addition to the tendon decompression the inferior pole of the patella is explored and the bony spur is excised.

Rehab after surgery for patellar tendonitis does vary according to the severity of the condition and the corresponding magnitude of the procedure performed. However, the standard protocol follows the approximate guidelines of:

• Day 1 – Week 6: Partial weightbearing with a crutch +/- a knee brace
• Week 6 – Week 12: Physiotherapy to regain range of motion and muscle strength, but no running, jumping, hopping, squatting or heavy weights.
• 3 months onwards: Gradual return to full activities and sports under the supervision of an appropriate physiotherapist.

Quadricep tendonitis

This condition is similar to patellar tendonitis (see above), except that it occurs in the distal (lower) part of the quadriceps tendon at the upper part of the front of the knee, at the superior (upper) pole of the patella.

Quadriceps tendonitis can be confirmed by ultrasound scanning, and it normally responds well to conservative treatments, only relatively rarely requiring surgical treatment.

Iliotibial band friction syndrome

This is a condition whereby sufferers feel a burning pain around the lateral (outer) part of the knee, overlying the region of the lateral epicondyle of the femur. Pain may radiate up the lateral side of the thigh. The pain usually only comes on with exercise, typically running, and often only comes on after a set distance or time from onset of exercise. The pain normally eases fairly rapidly with rest, although a persistent aching around the area is common.

The condition occurs due to some relatively unusual anatomy in this part of the knee. The iliotibial band is a sheet of fascia running down the lateral side of the thigh. Proximally, at the top of the thigh, there is a muscle – tensor fascia lata – that originates from the pelvis and which passes down, attaching to the top of the fascia lata. The whole structure is referred to as the iliotibial band. The fascia lata passes distally, attaching to the proximal tibia at a region called Gerdy’s Tubercle. At the side of the distal end of the femur, there are prominent lumps of bone on either side of the knee; the medial and lateral epicondyles. These are the points of origin of the medial and lateral collateral ligaments.

With the knee flexed, the iliotibial band (ITB) sits posterior to (behind) the bony prominence of the lateral epicondyle. When the knee is flexed to about 20 or 30 degrees, the ITB lies directly over the lateral epicondyle. When the knee is fully extended, the ITB sits anterior to (in front of) the lateral epicondyle. Between the ITB and the lateral epicondyle there is a thin sack of fluid (a bursa) that helps reduce friction between the fascia and the bone. However, if the epicondyle is particularly prominent, if the ITB is over-tight and if the patient undertakes large amounts of exercise, then the ITB can rub excessively on the epicondyle, leading to inflammation, with associated pain.

Treatment of ITB Friction Syndrome is based on conservative measures, including:

• Rest
• Avoidance of activities that trigger the symptoms
• Use of anti-inflammatories
• Physiotherapy
• Local steroid (cortisone) injections

In situations where conservative measures fail, then surgical treatment may become necessary. This involves making an incision (normally about 5cm long) longitudinally over the lateral side of the knee and then releasing the distal ITB either through a small posterior snip in the tissue or, where necessary, through a larger release and lengthening procedure as appropriate depending on the severity of the condition.

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The main ligaments of the knee are:

• The anterior cruciate ligament
• The posterior cruciate ligament
• The medial collateral ligament
• The lateral collateral ligament
• The ‘posterolateral corner’

ACL

The anterior cruciate ligament is a thick strong ligament in the middle of the knee. It originates from the middle of the front of the tibia and passes upwards, backwards, and laterally (outwards), attaching to the femur on the medial (inner) side of the lateral femoral condyle. The ligament stops the tibia from sliding too far forwards on the femur (also stopping the femur from slipping too far backwards on the tibia).

PCL

The posterior cruciate ligament is the largest and strongest ligament in the knee. It originates from the middle of the back of the tibia and passes upwards, forwards and medially, attaching to the femur on the lateral side of the medial femoral condyle. The PCL stops the tibia from sliding too far backwards on the femur (also stopping the femur from slipping too far forwards on the tibia).

MCL

The medial collateral ligament is situated on the inner side of the knee. It is a broad thick ligament with a short deep portion and a longer superficial part. It prevents the lower leg from bending outwards (into valgus).

LCL

The lateral collateral ligament is situation on the outer side of the knee and is a thin cord-like ligament. It passes from the lateral epicondyle of the femur to the fibular head and prevents the lower leg from bending inwards (into varus).

PLC

The structures of the posterolateral corner have only really become the focus of particular interest over the last 5 to 10 years or so. The posterolateral corner is a complex region of the knee and includes the popliteus muscle/tendon, the arcuate ligament, the popliteofibular ligament and the lateral collateral ligament. Things are made more difficult by the fact that so many of the descriptions of the anatomy of the PLC differ significantly in their interpretation of the region. Regardless of the finer points, the PLC functions so as to limit excessive external rotation of the tibia on the femur.

Ligament sprains

Ligament sprains (ie partial tears) are common, especially around the ankle joint. Sprains of the knee joint are frequently quite serious. The most common ligament sprain on the knee probably involves the medial collateral ligament. This is the ligament along the inner side of the knee that prevents the knee from bending out sideways. It is particularly vulnerable to twisting injuries or injuries from football or rugby tackles.

The medial collateral ligament of the knee is a thick, strong and broad ligament. Even quite severe tears normally heal up well, with conservative (non-surgical) treatment. The more severe ligament injuries may require treatment in a knee brace, to protect the ligament as it heals. However, management of medial collateral ligament sprains is normally best supervised by an appropriately trained physiotherapist.

Ligaments ruptures/tears

The most common ligament rupture in the knee is a tear of the ACL. However, ligament tears frequently occur in conjunction with other injuries within the knee, such as meniscal cartilage tears, articular cartilage damage or ruptures of other ligaments in or around the knee.

ACL ruptures

The anterior cruciate ligament is the ligament most frequently torn by sportswomen or men, often in sports such as football, netball or skiing.

Arthroscopic view of a normal ACL

Arthroscopic view of a torn ACL

The typical history and symptoms of an ACL tear are:

• History of a specific significant injury, such as a bad fall skiing or a nasty tackle playing football or rugby.
• The knee gives way with severe pain, and sometimes a specific ‘pop’ or ‘tear’ is felt or heard.
• The knee is then severely painful and tends to swell up rapidly, with difficulty weight-bearing.
• The athlete is normally unable to continue with the game.
• The swelling of the knee may take a few weeks to gradually go down (it is caused by bleeding into the knee from the torn ligament).
• Patients may then complain of ongoing instability in the knee, with a regular giving way and a feeling that the knee is ‘wobbly’, ‘unsteady’ or ‘not right’.

An ACL tear is a very significant injury to the knee. ACL tears frequently occur in association with other intra-articular damage. Early referral to a Consultant Orthopaedic Surgeon with a specialist interest in this field is essential.

Depending on the patient’s history, symptoms and clinical signs, patients are often referred for an MRI scan of the knee. MRI scans do not give a 100% accurate image of the inside of the knee; for example the accuracy of MRI for detecting meniscal tears is only in the region of about 80%. However, MRI may give useful information regarding the various structures in the knee, in particular the articular cartilage.

Treatment of ACL tears

Deciding on the correct treatment strategy for an ACL tear is a complex issue and decisions are tailored to specific individual patients based on their age, medical fitness, activity levels, sporting involvement and aspirations.

Even without an anterior cruciate ligament, some patients are able to regain a functionally stable knee without any reconstructive surgery, simply by strengthening up the muscles of the knee and improving the reflexes (proprioception). This is achieved through an intensive rehabilitation programme under the supervision of an appropriately trained physiotherapist. However, with conservative treatment, although a good proportion of patients are able to cope, many end up unable to return to their same pre-injury exercise and sporting levels.

The most clear indication for surgical ACL reconstruction after an ACL tear is in those patients suffering recurrent giving way of the knee. Each time the knee gives way further damage is potentially being caused inside the knee to the articular cartilage and to the meniscal cartilages, with the risk of worsening long-term outcomes.

PCL and PCL tears

90% of PCL tears and 90% of PLC tears occur in association with other ligament injuries within the knee; mainly rupture of the ACL.

Isolated PCL tears have a very good likelihood of responding well to conservative treatment with physiotherapy, without the need for surgical reconstruction.

Combined tears of the ACL + PCL, the ACL + PLC or the PCL + PLC usually cause quite severe functional instability in the knee joint, and normally do require surgical reconstruction.

Complex multi-ligament reconstructions of the knee are a fairly major undertaking – far more so that a simple isolated ACL reconstruction. Multiple ligament reconstructions can normally be undertaken with just 1 or 2 nights’ stay in hospital post-operatively, but usually require a patient to have a knee brace post-op, with a slower more cautious rehab regime.

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What is articular cartilage?

Articular cartilage is the layer of very smooth shiny white tissue inside a joint, which covers the ends of the bones. Articular cartilage varies in thickness from just a millimetre up to several millimetres; the heavier the loads across any specific joint, the thicker the cartilage.

Articular cartilage is extremely smooth and hence is very low friction, allowing the ends of the bones to move freely against each other without catching or rubbing. Indeed, articular cartilage has a lower coefficient of friction than any other known material – natural or man-made.

Knee joint opened up and viewed from the front/top. The articular cartilage is a layer of smooth shiny white tissue covering the end of the femur, the top of the tibia and the back of the patella.

What is cartilage damage?

Articular cartilage can be damaged by trauma, degenerative wear and tear or other specific joint diseases.

Causes of articular cartilage damage:

• Trauma, eg fractures into the joint
• Degenerative, eg osteoarthritis
• Inflammatory, eg rheumatoid arthritis
• Others, eg Osteochondritis Dissecans

Unfortunately, articular cartilage, once damaged, does not heal itself with new normal tissue, as bone does. The structure of articular cartilage is complex, and it is referred to as ‘hyaline cartilage’. At best, areas of damage or cartilage loss may heal up with what is known as ‘fibrocartilage’, which is half scar tissue and half like cartilage. However, fibrocartilage does not have the same biological or mechanical properties as normal hyaline cartilage. At the extreme end of the spectrum, damaged cartilage may lead to patches of bare bone developing within a joint, with all the usual painful symptoms and signs of arthritis.

Surgeons often grade cartilage damage according to varying scoring systems. Probably the simplest and most commonly used is a four-point score based on the visual appearance of the cartilage on inspection at arthroscopy:

• Grade I – Softening of the cartilage
• Grade II – Roughening of the surface of the cartilage
• Grade III – Fissures / cracks in the cartilage, going down to bone
• Grade IV – Cartilage loss down to bare bone

Intra-operative arthroscopic view of a large patch of Grade IV articular cartilage damage. Central V-shaped pink area = bare bone.

Loose bodies

In addition, small pieces or even large chunks of cartilage (or bone + cartilage) can break off inside the knee, becoming what is referred to as a ‘loose body’. Loose bodies can cause pain, swelling, locking and intermittent giving way of the knee.

Loose piece of cartilage in knee

What are the symptoms of articular cartilage damage?

Cartilage damage can cause quite a wide variety of potential symptoms, depending on the severity of the damage. Symptoms may include:

• Pain in the joint
• Swelling of the joint
• Catching or giving way
• Locking (where one is unable to fully straighten the joint)

If the area of cartilage damage is small, then a patient may feel a quite specific, localisable, intermittent sharp pain within the joint. If the cartilage damage is extensive and widespread, then the symptoms are more likely to be those of generalised arthritis.

Further information

For further information about articular cartilage damage and its treatment options, click here:  http://kneearthroscopy.co.uk/condition/articular-cartilage-damage/

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Symptoms at the front of the knee may be due to a variety of possible causes. The exact site of the pain and the nature of the actual symptoms will give a strong guide as to the potential likely causes.

Site of the pain

Pain directly behind the kneecap – this implies that there might be some damage (cartilage damage or arthritis) in the joint where the back of the kneecap contacts the front of the knee – the patellofemoral joint. Problems with the patellofemoral joint can be caused by trauma (eg falling directly onto the front of the knee), by wear and tear (degeneration/arthritis) or problems can arise due to biomechanical problems, such as maltracking (where the kneecap sits too far over to one side rather than sitting normally in the middle of the front of the knee).

Pain in front of the kneecap with swelling – can be due to an inflamed sack of fluid called prepatellar bursitis.

Pain just below the kneecap – this can be due to either inflammation of the patellar tendon (patellar tendonitis) or scarring/inflammation of the tissue behind the patellar tendon (known as the fat pad).

Pain around the inner side of the front of the knee – this can be due to a shelf of scar tissue inside the knee rubbing, called a medial plica.

Why is anterior knee pain worse with certain activities?

When the knee is relatively straight and the quadriceps muscles contract, the kneecap is pulled upwards and the forces between the back of the kneecap and the front of the knee are not that great. However, when the knee is bent (flexed), the large forces of the contracting quads, pulling the kneecap one way, are counterbalanced by large tension in the patellar tendon, attaching the kneecap to the front of the shin. The resultant force is a massive force pushing the kneecap hard onto the front of the knee.

This is why anterior knee pain is so often worse with certain specific activities, such as:-

• going up / down stairs (particularly down)
• sitting for long periods (eg in a cinema)
• driving long distances

The knee feels like it ‘pops out’

People who suffer from ‘dislocations of the knee’, with feelings of the knee popping out are often suffering from patellar instability.

The back surface of the kneecap is V-shaped and it sits, like a keel, in a groove than runs in the front of the knee (the trochlear groove).

In some patients, the groove in the front of the knee is too shallow (trochlear dysplasia) and the back of the kneecap is flatter than it should be. The kneecap tends to slip out too far to the outer (lateral) side, and can dislocate sideways out of the groove in the front of the knee as the knee is bent.

Other patients with normal knee anatomy may suffer a traumatic patellar dislocation after trauma, and this can cause ongoing patellar instability.

Patellar instability is a serious condition. Apart from the fact that when the knee gives way, the individual may fall over and badly hurt themselves, each time the patella dislocates the structures inside the knee such as the articular cartilage can suffer increasing levels of damage, increasing the risk of arthritis in the knee in the future. Also, with every dislocation the soft tissues at the front of the knee get stretched further, potentially making the patella even more unstable and increasing the likelihood of further additional dislocations in the future.

Patients suffering from patellar instability should be investigated thoroughly as soon as possible – often with X-rays and MRI scans and sometimes with keyhole surgery (arthroscopy), to indentify the exact contributory causes of the instability so that a treatment plan can be tailored to each particular patient’s problems. This often requires surgical stabilisation procedures.

Patellar maltracking

This is a very common problem. Maltracking pretty much always means lateral maltracking of the patella. The patella normally runs smoothly up and down the trochlear groove in the middle on the front of the knee. However, if the patella sits too far over to one side, then it will rub against the edge of the trochlear groove and cause pain from pressure overload and, eventually, increased wear and tear.

There are many reasons for lateral patellar maltracking, with patients often having more than one of the possible contributory factors at the same time. Some of the things that may cause maltracking include:-

• weakness in the vastus medialis (VMO) muscle on the inner side of the knee
• tight tissues on the lateral (outer) side of the knee
  inwardly rotated hips
• an outwardly angled shin bone (valgus knee)
  flat and outwardly rotated feet (pronated planovalgus feet)
• trochlear dysplasia (too shallow a groove in the front of the knee)
• patellar dysplasia (back surface of the patella flat instead of ‘V’-shaped)
• patella alta (where the kneecap sits too high up at the front of the knee)

As you can see, with this many different things potentially contributing to patellar maltracking, it is essential that the whole leg is assessed fully, both by thorough clinical examination and also with X-rays and/or MRI scans. Only when a very clear picture of the causes has been identified can one formulate a proper treatment plan.

Chondromalacia patella

Artroscopic view of the patellofemoral joint

Chondromalacia patella is softening of the cartilage at the back of the kneecap. It causes pain around the front of the knee. It can arise secondary to excess stress on the kneecap from pressure overload secondary to problems like maltracking. However, in young females (teenage / twenties) if often comes on for no apparent cause.

It is important to make sure that the knee is investigated fully, to rule out underlying pathology. If there is nothing at all wrong with the knee apart from just soft cartilage on the back of the patella, then this is best treated by rest (avoiding things that bring on the pain) plus possibly physiotherapy.

Medial plica syndrome and scarring/inflammation of the fat pad

When the knee joint forms in the developing embryo, it starts as two separate compartments; one for the developing femur and one for the developing tibia. The two compartments gradually fuse together, forming the one single cavity of the knee joint. In many people (about 15% of the population) the shelf of tissue in the knee from where the compartments fused together fails to shrink away completely and they are therefore left with shelves or bands of soft tissue inside the knee. These shelves/bands of tissue are called plicae.

The most common plica is a medial plica, which sits at the front inner side of the knee. At the very front of the knee, behind the kneecap and patellar tendon, there is another band of tissue that is sometime present, called the ligamentum mucosum.

In those people who have these shelves/bands of tissue but the tissue is thin and the person is not very physically active, the plicae may cause no symptoms at all. However, if the plicae are thick and if the patient does a lot of exercise, then the plicae can rub inside the knee and become inflamed.

Inflamed plicae cause pain in the knee, normally around the front/inner side or directly behind the patellar tendon. Patients tend to be able to start running but the pain then comes on gradually and gets worse the further they run.

If a plica is causing bad enough symptoms to stop someone from exercising or playing sport, then it is worth having it treated. Treatment of plicae is straight forward. You can try a steroid/cortisone injection, but these often fail to help with plicae. However, the definitive treatment is to have a knee arthroscopy (keyhole surgery), where the plica or ligamentum mucosum is simply removed. The plicae have no actual function in the knee and most patients make a fairly rapid and complete recovery and are able to get back to full activities/sport.

Patellar tendonitis

Patellar tendonitis is also knows as ‘Jumper’s Knee’. The forces across the knee with running and other forms of exercise are huge. The massive forces generated by the quadriceps muscles are transmitted through the kneecap and then down to the tibia (shin bone) by the patellar tendon, which attaches to the tibia at the lump of bone called the tibial tuberosity.

MRI demonstrating patellar tendinosis and ossicle (Osgood-Schlatters disease)

Any tendon in the body can get inflamed, particularly tendons that receive a lot of use. Inflammation in the tendon causes pain that tends to come on with exercise. Pain from patellar tendonitis is felt at the front of the knee, just below the kneecap, and is made worse by activities such as running, squatting or going up/down stairs a lot.

If patellar tendonitis is present for too long then the tendon can become degenerate and full of scar tissue. The scar tissue acts as a block, preventing new blood vessels from growing into the area to heal up the tendon.

In some patients, a small beak of bone can develop at the bottom tip (inferior pole) of the patella, which presses and rubs against the back of the top part of the patellar tendon when the knee bends. This is called patellar impingement, and can be an underlying cause of patellar tendonitis.

The two best investigations for diagnosing patellar tendonitis are MRI or Ultrasound scans.

Mild symptoms from patellar tendonitis or tendinosis can be managed with:

• anti-inflammatories
• rest
• physiotherapy

For more serious or persistent symptoms one option available is to perform Dry Needling of the tendon. This involves puncturing the patellar tendon in multiple spots with a small needle through the skin with some local anaesthetic. This causes small amounts of bleeding into the tendon which seems to initiate a healing response, helping the tendonitis to settle down. The results of Dry Needling are best when the technique is combined with physiotherapy treatments, particularly focusing on what are termed ‘eccentric loading’ exercises.

In cases where non-surgical treatments have failed, surgery can normally give a very good chance of curing patellar tendonitis or tendinosis.

Surgery involves having an arthroscopy (keyhole surgery) of the knee to check everything from the inside, combined with a mini-open tendon decompression. This is where the inflamed or degenerate portion of the tendon is trimmed away. The surgery encourages new blood vessels to grow into the area, which helps the tendon to heal up. At the same time, underlying causes like bone spurs on the patellar, can easily be trimmed away to prevent tendon impingement.

Surgery for patellar tendonitis/tendinosis is not large and is usually very successful. However, it does require an extensive period of rehab, with 6 weeks rest (often with crutches) followed by 6 weeks of intensive physiotherapy, with return to running or impact delayed until 3 months post-op at the earliest.

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Arthritis of the knee is a painful condition, where the cartilage in the knee joint wears away, leaving bone rubbing on bone within the joint. The symptoms are normally an aching or burning pain within the joint, swelling and stiffness. Sometimes there may also be cartilage tears or loose pieces of cartilage or bone within the joint, and these may cause sudden sharp pains, locking (when the knee becomes fixed) or giving way of the knee. With severe arthritis, the joint becomes very painful and stiff and the knee may become deformed, leading to either a bow legged or knock kneed appearance.

X-rays of a normal knee (left) and an arthritic knee (right).

Image of a patient with severe osteoarthritis of the right knee – note the swelling of the knee with the varus deformity (bow legs).

Non-surgical treatment options for early knee arthritis include:

• Walking aids
• Glucosamine and/or chondroitin sulphate tablets
• Simple painkillers
• Anti-inflammatories
• Physiotherapy
• Joint injections (of steroid or hyaluronic acid)

When the various non-operative measures have failed to control the symptoms of knee arthritis, surgical treatment becomes an option for those patients with significant symptoms.

Surgical treatments for arthritis of the knee include:

• Knee arthroscopy and washout (for cases of early arthritis, or where there are mechanical symptoms such as regular giving way)
• Partial knee replacements
• Total knee replacement
• Fusion of the knee (this is rarely ever performed – and normally only as a salvage procedure)

For further information about knee arthritis, click here:  http://kneereplacements.co.uk/knee-arthritis/

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