In the simplest terms, a joint occurs wherever two bones come together; however, that definition does not begin to convey the complexity of joints, which provide your body with flexibility, support and a wide range of motion.
You have four types of joints: fixed, pivot, ball-and-socket and hinge. Your knees are hinge joints. As the name suggests, they work much like the hinge of a door, allowing the joint to move backward and forward. Your knees are the largest and heaviest hinge joints in your body, and the most complex. In addition to bending and straightening, they twist and rotate. This makes them especially vulnerable to damage, which is why they sustain more injuries on average than do other joints.
Your knee joint is essentially four bones held together by ligaments. Your thighbone (femur) makes up the top part of the joint, and two lower leg bones, the tibia and the fibula, comprise the lower part. The fourth bone, the patella, slides in a groove on the end of the femur.
Normally, all of these structures work together efficiently, but injury and disease can disrupt this balance, resulting in pain, muscle weakness and decreased function.
If you’re suffering from knee pain, you are not alone. Almost one in three Americans older than age 45 reportssome type of knee pain. It is a common cause for doctor and emergency room visits.
Ligament Injuries: Your knee contains four ligaments — tough bands of tissue that connect your thighbone (femur) to your lower leg bones (tibia and fibula). You have two collateral ligaments — one on the inside (medial collateral ligament) and one on the outside (lateral collateral ligament) of each knee. The other two ligaments are inside your knee and cross each other as they stretch diagonally from the bottom of your thighbone to the top of your shinbone (tibia). The posterior cruciate ligament (PCL) connects to the back of your shinbone, and the anterior cruciate ligament (ACL) connects near the front of your shinbone. A tear in one of these ligaments, which may be caused by a fall or contact trauma, is likely to cause:
Tendon Injuries (tendinitis): Tendinitis is irritation and inflammation of one or more tendons — the thick, fibrous cords that attach muscles to bones. Athletes, especially runners, skiers and cyclists, are prone to develop inflammation in the patellar tendon, which connects the quadriceps muscle on the front of the thigh to the larger lower leg bone (tibia). If your knee pain is caused by tendinitis, some of the signs and symptoms include:
Meniscus injuries: The meniscus is a C-shaped piece of cartilage that curves within your knee joint. Meniscus injuries involve tears in the cartilage, which can occur in various places and configurations. Signs and symptoms of this type of injury include:
Bursitis: Some knee injuries cause inflammation in the bursae, the small sacs of fluid that cushion the outside of your knee joint so that tendons and ligaments glide smoothly over the joint. Bursitis can lead to:
Loose body: Sometimes a piece of bone or cartilage will break off and float in the joint space because it has degenerated or sustained injury. This may not create any problems unless the loose body interferes with knee joint movement. The effect is similar to a pencil caught in a door hinge — leading to pain and a locked joint.
Iliotibial band syndrome: This occurs when the ligament that extends from the outside of your pelvic bone to the outside of your tibia (iliotibial band) becomes so tight that it rubs against the outer portion of your femur. Distance runners are especially susceptible to iliotibial band syndrome, which generally causes:
With this type of knee injury, there usually isn’t swelling and you’ll likely have normal range of motion.
Rheumatoid arthritis: The most debilitating of the more than 100 types of arthritis, rheumatoid arthritis can affect almost any joint in your body, including your knees. Common signs and symptoms include:
Although rheumatoid arthritis is a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares, often alternate with periods of remission.
Osteoarthritis: Sometimes called degenerative arthritis, this is the most common type of arthritis. It’s a wear-and-tear condition that occurs when the cartilage in your knee deteriorates with use and age. Osteoarthritis usually develops gradually and tends to cause:
Chondromalacia of the patella, or patellofemoral pain: These are general terms that refer to pain arising between your patella and the underlying thighbone (femur). It is common in young adults ( especially those who have a slight misalignment of the kneecap), in athletes and in older adults who usually develop the condition as a result of arthritis of the kneecap. Chondromalacia of the patella causes:
History and Examination: A history of your complaints including duration, what makes it better and worse is very important. Previous treatments and outcomes, as well as orthopedic examination of the muscles, joint, movement and strength are also used for diagnosis
X-rays: Plain X-rays can show narrowing of the space in the two joints of the knee —revealing wear and tear on the cartilage from arthritis like diseases and bone spurs that can interfere with movement.
MRI: Magnetic Resonance Imaging: Is a noninvasive procedure that can reveal the detail of knee ligaments, tendons and cartilage including tears in the meniscus.
Myelography/CT scanning: Sometimes used as an alternative to MRI
Diagnostic ultrasound Imaging: Unlike an x-ray, which emits radiation and shows only bone, diagnostic ultrasound is non-invasive and allows for viewing the causes of your knee joint pain with great accuracy. With musculoskeletal ultrasound imaging (MSUS), the muscles, tendons, ligaments, cartilage and joint can be accurately examined at the time of your visit. This provides immediate information about the health of your joint and what factors are contributing to your pain. With this information in hand, specific treatment options can be established immediately!
When the joint is painful or damaged there are a variety of successful treatment options.
When using an injection to deliver treatment into painful joints, it is necessary to be exact and precise.
Dr. Isidro and his team are highly trained in ultrasound-guided injections. These procedures are performed in the office, at the time of your visit. Some of the common structures involved in joint pain may be as little as 2-3mm wide and therefore require a high level of precision to be accurate. In addition, when performing an injection, there are also structures that you want to avoid so you don’t knick or damage them on your way into the joint. The ultrasound machine provides live imaging in real time, to safely place injectable medications or treatments into or around the joint with laser-like precision.
Consider trying to hit a target blindfolded¾you may know the general direction but would not be certain if you have actually hit your target. With live ultrasound imaging, the targeted areas of pain are viewed in real time while the injection is taking place, guiding the needle with pin-point accuracy!
Cortisone Injection: Painful arthritic joints, chronic tendinitis, bursitis and inflammation respond quickly to cortisone. In many cases this is the head start patients need to allow for gains with more conservative care and no further treatment is required. Many patients think that cortisone is bad for you. Too much of anything is not good. Using cortisone infrequently, as much as several times per year will not do any harm. If the pain continues to return, other treatment options should be considered.Cortisone is injected using continuous live ultrasound guidance exactly where it is needed to quickly reduce inflammation and pain.
A squeaky gear needs the most oil!
The joints of the body are normally surrounded by a lubricant and shock absorber called Synovial fluid. Patients with osteoarthritis experience pain and inflammation because arthritic damage in thejoint causes the Synovial fluid to break down over time.
This process causes increased friction and excess wear and tear on the cartilage cushioning movement that becomes rough and jagged causing the joint further deteriorate. Range of motion, walking, getting up from a seated position, climbing and descending steps and weight bearing is often painful. Pain is often increased during or after activity.
Hyalgan is a naturally derived lubricant that instantly cushions and lubricates painful arthritic joints. By restoring lubrication and cushion, your joints move more freely again with less friction and most importantly, less pain. Hyalgan is injected using continuous live ultrasound guidance ensuring pin-point accuracy exactly where it is needed.
When there is damage, tissue tears or arthritis, this exciting new procedure (made popular by professional athletes) that heals damaged structures in a joint such as the labrum, tendons, muscle, ligament or cartilage is showing exciting results!
When you cut your skin and it bleeds, platelets collect and gather at the wound site. Once there, platelets act like a conductor in an orchestra. They release growth factors that signal the healing activities to begin, resulting in a cascade of events that restore the damaged tissue.
Joints, however, do not have a direct blood supply. Therefore, when a joint structure is damaged or torn, platelets do not gather and orchestrate the necessary events for that damage to be restored. Joint damage either heals slowly or not at all. That is where Platelet Rich Plasma Therapy (PRP) proves valuable!
By taking a small sample of your blood, a special centrifuge concentrates and separates the platelets, growth factors and specialized white blood cells from the other components of the blood. This super concentrated PRP is then injected using continuous ultrasound guidance into the cracks and crevices of the damaged area. The orchestra of events is stimulated and the tissue begins to heal. The result is reduced inflammation and pain.
As with the explanation above regarding platelets, damage in the body is healed by an orchestrated cascade of events guided by the release of specific growth factors in the areas where damage occurs. Because joints and surrounding tendons lack a direct blood supply, damage heals slowly or often not at all.
AmnioFix is hydrolyzed micronized amniotic membrane allograft. AmnioFix contains 13 powerful growth factors. That’s a mouth full! Amniotic Membrane has been used in wound healing for many years. By placing the allograft over wounds that aren’t healing, as with burn victims, new tissue grows. Just recently, the allograft has been processed into a form that is dehydrated and micronized.
AmnioFix is pre-packaged and injected using continuous, live ultrasound guidance exactly where the damage is. This begins to jump start and boost the healing response so joints function better with less inflammation and less pain.
We see many patients who come to us in chronic pain. Many have also had experience with physical therapy where they spent much of their sessions doing exercises and it hasn’t helped. Think of being in pain, having joint stiffness, loss of range of motion or chronic inflammation and then doing exercises to get rid of it. In most cases, you’ll feel worse not better.
Exercise is critical to maintain proper joint strength, but done at the wrong time and your pain often becomes worse. That is why we take an entirely different approach with treatment plans using three phases:
Our physical therapy team specializes in using certain modalities like electrical stimulation or ultrasound to reduce swelling and inflammation and increase local circulation to help the healing process. Different modalities can be applied to successfully address spasm, trigger points, inflammation, edema, swelling and damage from tendonitis and tears.
Techniques are done by hand to gently stretch, massage and release the pressure in each of the muscles, tendons and ligaments surrounding the joint. The result is a soothing improvement in joint pain.
Our physical therapy team is certified in the Selective Functional Movement Assessment (SFMA), which is a series of 7 full body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known joint pain. When the clinical assessment is initiated from the perspective of the movement pattern, our therapy team has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main joint pain complaint, but contribute to the pain.
Think of having a painful right knee and favoring that side for an extended period of time. Following a period of uneven gait you may develop pain on the opposite unrelated side. This concept, known as Regional Interdependence, is the hallmark of the SFMA.
The assessment guides our clinical physical therapist to the most dysfunctional non-painful movement pattern, which is then assessed in detail. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain.
You should see your doctor if: