John D. Burrow, DO
In Parts I-III of this series, Dr. Boyd Haynes has worked his way up the leg from the feet to the ankles, shins, and calves to discuss common musculoskeletal problems that can cause limping. I am going to pick up the discussion with the knees and review the most often seen issues that can cause limping.
Our knee joint is composed of the large femur bone that runs from our hip to our knee with the two lower leg bones, the tibia and fibula. The knee also has the patella or the kneecap that articulates with the knee joint which runs along a groove in the bone. There are quite a few muscles, tendons and ligaments which help to stabilize the knee joint while also allowing for exceptional movement. There are also different types of cartilage inside the knee joint, one of which makes up the meniscus which helps the joint to glide smoothly when in motion. When any of these components are injured, diseased or compromised, pain and limping may be the result.
Knee arthritis is probably the number one reason for knee pain, and it can certainly cause a limp. Osteoarthritis, or wear-and-tear arthritis that comes with aging, is the type that I most often diagnose and treat. Its symptoms start with pain, stiffness with inactivity, swelling, change in gait, difficulty standing or sitting, and problems with stairs. I diagnose arthritis by ordering x-rays, doing a thorough physical exam, and asking a lot of questions of the patient.
Treatment starts conservatively, typically with NSAIDS, Physical Therapy, heat, exercise, and a recommendation to lose weight if needed, as this helps to take pressure off your knee joint. Oral steroids or steroid injections are also helpful to reduce inflammation. As arthritis progresses and becomes more painful, we also can try Visco-supplementation with hyaluronic acid injections. Eventually, arthritis will progress to stage four, which is bone-on-bone. With progression and continued symptoms, a knee replacement may be the recommended course of treatment. Knee replacement surgery is now done on an outpatient basis for almost everyone and recovery takes anywhere from four to ten weeks for most people.
Ligament and tendon sprains and tears of the knee are also quite common because the knee can easily be injured, whether by playing sports, pivoting, or twisting on the knee as we get older, sometimes just during normal movement or during a fall. Symptoms will be more pronounced depending on the severity of the injury, with bruising, swelling, and pain. The limp or ability to walk will also depend on the grade of the injury or tear.
Treatment for sprains and incomplete tears will be elevation, intermittent icing, rest, NSAIDs, bracing, possible non-weight bearing for higher grade injuries with the use of crutches for a few weeks and Physical Therapy. Complete tears will typically need surgical repair done on an outpatient basis. Patients can expect to be non-weight bearing for several weeks before starting Physical Therapy. Recovery times can take up to six months for complete tears with surgical repair.
Meniscal tears are little tears of supportive cartilage in the knee joint cartilage typically through an injury to the knee, although they can simply occur through the process of aging. They can cause the knee joint to feel as if it is catching or has something stuck in it, causing pain and a limp. To confirm a suspected meniscal tear, I must order an MR scan, because x-ray cannot visualize cartilage, only bone.
Unfortunately, the meniscus has a poor blood supply, so the chances of healing the tear on its own are slim to none. Our options with these tears are 1) try Physical Therapy, steroid medications and wait and see, OR 2) arthroscopic surgery to repair the tear and clean up the little piece of jagged meniscus that may be causing the “catch” in the knee. Recovery from this outpatient procedure is quick, with the patient on crutches for a few days, with intermittent icing and elevation of the knee. The patient should expect to be completely well and fully ambulatory in four to six weeks, depending on the complexity of the tear.