Second Opinion on Knee joint conditions

The knee joint consists of very sensitive structures and is therefore highly susceptible to injury and wear. Persistent problems, such as pain or swelling, should not be neglected since they usually indicate a condition requiring the care of an orthopedic specialist. Treatment options vary from physiotherapy to various surgery types. In many cases, a number of alternatives may be considered. A second opinion can provide the guideline and help to solve the issue.

Knee conditions: how will you know you have one?

The largest joint in the human body, the knee plays a major role in walking and running, normally without making itself particularly noticeable. The basic message it uses to signal a problem is pain. Depending on the issue, it may be sharp or dull, occur in motion or at rest, last temporarily, or persist. In any case, this sign should not be overlooked, especially if it is accompanied by swelling, difficulty in motion, a feeling of instability, or stiffness. Alone or all together, these symptoms indicate damage to one or more knee structures.

A glimpse into anatomy

The knee is made up the femur (thigh bone), tibia (the main bone of the lower leg), and the kneecap (patella). Their contact surfaces are covered with articular cartilage – a very special tissue which protects the bones and ensures smooth movement.

The kneecap lies between two bands of dense connective tissue which are called tendons. The whole structure is stabilized by a complex ligament system, including the inner, the outer and the cruciate ligaments.  The latter is ligaments play an important role in the knee joint.

The menisci are located on the inside and outside between the joint surfaces and act as shock absorbers; made of fibrocartilage (a dense mixture of fibrous and cartilage tissue), they also improve joint contact and add more stability to the joint.

What will your doctor do to find out the cause of your knee issue?

An orthopedic examination starts with taking a comprehensive case history, including the duration and type of complaints. This basic data is usually enough to provide the initial insight into understanding a knee condition. One of the key issues is to find the cause of the pain, which can be the knee itself, but also the lumbar spine, the hip joint, or even metabolic disorders (e.g., gout).

The further procedure may include a case-specific X-ray study, which can detect dislocations, fractures, arthroses, loose bodies, calcium deposits, and other abnormalities. An ultrasound scan is used to evaluate the knee tendons, ligaments, and muscles. In many cases, magnetic resonance imaging is required for their more precise assessment.

Computed tomography may be needed to assess blood flow and look for signs of inflammation. A bone scan (scintigraphy) can help to diagnose abnormal metabolic activity in the knee tissues.

Knee disorders: an overview

Knee osteoarthritis

Stress on the knee, bone deformities, obesity and injury may lead to gradual disintegration of the cartilage, so that the bones start to rub against each other, causing pain and making movements difficult. The general term for such wear and tear is osteoarthritis, whereas if it affects the knee, medical professionals call it gonarthrosis. 

Management methods fall into three basic types: non-drug therapy, drugs, and surgery.

Non-pharmacological approach is the use of orthotics, such as insoles or knee braces, as well as walking sticks, which serve to lessen the stress on the joint. Controlled weight loss can also help spare the knee. Symptomatic pain management is achieved through acupuncture, cryotherapy, thermotherapy, electrotherapy and ultrasound.

Drugs: a variety of medicines (steroids, non-steroidal anti-inflammatory drugs, salicylates, etc.) are available, which can ease gonarthrosis symptoms. They may be administered orally, rubbed on the knee or used as injections.  Alongside with hyaluronic acid, the pain-relieving effect of which has been clearly proven, substances made from the patient’s own blood (platelet-rich plasma, PRP) are injected in the knee to enhance the body’s own healing potential.

Surgery: depending on the disease stage, invasive procedures may include knee arthroscopy, cartilage grafting, osteotomy, or knee replacement (partial or total).

Cruciate ligament injury

Out of the four ligaments that stabilize the knee joint (the anterior and posterior cruciate, and two collateral ligaments), the anterior is the one that gets injured most often, especially in sportsmen. It can be either overstretched or torn; the latter case is especially painful and often requires surgical treatment.

A variety of tests are available to diagnose the condition. Often, the description of the accident alone provides clear indications of the injury type. An X-ray is taken to rule out the possibility of a bone fracture. The diagnosis is confirmed by an MRI (magnetic resonance imaging).

Treatment depends on the damage type, the degree of instability, the patient's age and physical activity pattern.

For minor tears physical therapy, bracing and reduction of activity may be enough. 

Full ruptures usually require a surgical procedure including replacement of the damaged ligament with the patient’s own tissue, such as the tendon parts of the knee flexor muscles, or more rarely, the patellar tendon. In terms of tensile strength and elasticity, these tendons are roughly comparable to the cruciate ligament and provide a good substitute.

Anterior cruciate ligament reconstruction is a safe and low-risk procedure. If indicated, it should not be delayed, since untreated rupture may lead to the destruction of meniscus or cartilage tissue, which will make it impossible to restore normal joint function.

Injured meniscus

Meniscus tear can be caused by wear and tear or by forceful twisting of the knee, e.g., in an accident. Signs, such as a popping sensation, swelling, stiffness and pain may take about 24 hours to develop. Sometimes the condition can heal on its own (rest, cold and medication help to relieve the symptoms). However, for certain types of ruptures, a surgical procedure is indicated. Its primary goal is to keep as much of the meniscus as possible in order to prevent further wear and tear of the joint.

The three meniscus surgery types are:

• Minimally invasive meniscus repair.

If the meniscus tissue still has sufficient blood supply, is not bruised or extremely degenerated, the tear can be repaired during an arthroscopic procedure using sutures or tiny anchors made of a special plastic (polyetheretherketone, or PEEK), so the meniscus is completely retained.

• Partial meniscus removal.

If it turns out that the tissue has no chance of healing again, the damaged part of the meniscus must be removed, and the remaining surface is smoothed. The advantage of this method is that follow-up treatment is relatively problem-free.

• Meniscal transplant surgery.

The prerequisite is a well-preserved articular cartilage without signs of arthrosis and a correct leg axis. The procedure is usually considered as an option for younger patients.

Seeking a second opinion on knee issues: a smart decision

Making decisions about health is usually not easy; knee disorders are not an exception. In an ideal case, one should better refer to a specialist with thorough knowledge of all available treatment options. However, such expertise is not easily found. The good news is: a lot of knee joint conditions can be evaluated at a distance. Modern telemedicine tools, such as radiology image transmission and online conference platforms allow for quality remote advise even in very complex cases. So, do not miss your chance to obtain a second, or even a third competent opinion.