Where is the pain?

Knee pain can occur for a variety of reasons. Just like in the hip, the location of the knee pain can give Dr. Waddell a clue as to what is causing the knee pain.  Further, typical causes of knee pain vary with age, just like in the hip.

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Generally, knee pain can occur on the inside of the knee (medial), the outside of the knee (lateral), front of the knee (anterior) and back of the knee (posterior). 

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Knee pain, no matter where is occurs, can be due to a muscle strain, medial meniscal tear, bursitis, or arthritis, among others. It is also important to make sure the knee pain is not actually pain referred down from the hip or the back.

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Dr. Waddell, just like in the hip, will use a thorough history, a physical exam, and other tests (like an X-ray), to determine the cause of the pain.

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Knee Anatomy
The knee is a "hinge" joint that primarily serves to flex and extend.  The knee has other small motions as well, but for the most part, it flexes and extends. The knee is made up of the lower end of the femur (thigh bone) and the upper end of the tibia (shin bone). The fibula, which is the smaller bone in the lower leg, is also a part of the knee as well, though not directly connected to the knee joint. These two bones are capped with a very smooth cartilage, called hyaline cartilage.  The knee is held together by ligaments, specifically the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments.  Inside the knee, there is a medial and lateral meniscus.  The meniscus serves to cushion the knee and help with knee function. 

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​Specific Causes of Knee Pain
Just like in the hip, there are many causes of knee pain. 

 

While it is typical that as we progress in age, we more commonly suffer from degenerative changes to the knee, such as arthritis, we are now seeing a significant rise in younger patients with severe degenerative conditions of the knee. The meniscus can also wear out with use and age as well. A few of these problems are discussed below.

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Referred Hip and Back Pain

Just as the back can refer pain to the hip, the back and the hip can refer pain down to the knee.  The pain in the back or hip can send signals down the nerves to the knee and trick the mind into thinking there is pain in the knee.  A good history and physical exam will be able to determine the specific cause of pain in most cases.

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Muscle Strain

Just like in the hip, muscle strains that cause knee pain occur when a muscle is injured, usually seen in the setting of trauma or an injury.  This pain can be anywhere around the knee and usually begins to get better with time and avoiding activities that cause the pain. 

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Meniscal Tear

As discussed above, meniscal tears have a bi-modal distribution (meaning they occur in two different populations of people: in young and in older patients).  In the young patient, a meniscal tear occurs in a trauma or injury situation.  These types of meniscal tears usually cause a catching or locking sensation that keeps the patient from bending or extending the knee.  It can take a while to "un-lock" the knee and begin to move it again.  This "locking" occurs because the torn portion of the meniscus gets caught inside the joint and causes so much pain the knee cannot move.  This type of injury can be treated with arthroscopic surgery.

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In patients who have progressed in age, the meniscus can wear out and have a "degenerative tear."  This means that the meniscus has degenerated, or worn out, over time.  This type of tear usually is seen in conjunction with arthritis and both problems can cause pain.  The pain is usually a strong, dull achy pain that is better with rest and worse with increased activity. 

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Bursitis Around the Knee

On the medial, or inside of the knee, there is a bursa (fluid-filled lubrication sack) that sits between the tibia and the hamstring muscles that attach to the knee. This bursa has a fancy name, called the "Pes Anserine Bursa."  "Pes" means foot and "anserine" means goose.  It's named that since the way the hamstring muscles insert onto the tibia, they form the shape of a goose's foot.  Sometimes this bursa can get inflamed, especially in those patients with tight hamstrings, and this will cause pain on the medial (inside) side of the knee, just below the joint line.  This pain is also dull and achy, but very sharp when pressed in the area of the bursa.  The treatment is usually rest, anti-inflammatories, stretching and physical therapy, and sometimes a steroid shot into the bursa.

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Arthritis

Finally, arthritis of the knee, whether Rheumatoid arthritis or Osteoarthritis, is usually a painful condition that stems from cartilage loss in the joint.  Young patients can have knee arthritis as well, and just like in the hip, it is being seen more commonly in younger patients.  Similar to the hip, arthritis is defined as the damage and loss of normal cartilage.  In Osteoarthritis, this damage and loss if from wear and tear.  In Rheumatoid arthritis, and other inflammatory arthritis conditions, the cartilage loss is from the body attacking itself and causing loss of cartilage. Arthritis of the knee usually begins as a nagging pain around the knee that is worse after activity.  The pain then progresses to hurting with most activities and limits activities.  As the knee begins to suffer from arthritis, patients will typically notice their leg is no longer straight.  When the medial compartment (the inside of the knee) wears out, patients begin to have a bow-legged appearance.  When the lateral compartment of the knee (the outside) wears out, the patients begin to have a knock-kneed appearance.  Treatment for arthritis usually begins with non-operative therapy, such as anti-inflammatories, physical therapy, and possibly injections.  Surgery is usually reserved for severe cases and/or those cases that fail non-operative therapy.

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How to Diagnose the Cause of the Pain
Similar to the hip, the most important tool Dr. Waddell uses to determine the cause of your knee pain is listening to you as the patient.  You know your body best and it is important for a surgeon to fully understand how the pain began, has progressed and has been treated so far.  It is very important to know what makes the pain better and what makes it worse.  After a detailed history, Dr. Waddell will perform a detailed physical exam which is essential in the diagnosis of your knee condition.

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The next step in the process will be X-rays.  Many patients have taken previous X-rays and while those sometimes will work, Dr. Waddell has specific X-ray views that studies have shown to be superior than standard X-rays.  If your previous X-rays did not include the specific views, then it will be necessary to get these X-rays so he will have the best chance to accurately diagnose your condition. 

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Treatment Options

Most orthopedic treatments begin with a similar initial treatment. The first step is to avoid activities that hurt.  When this becomes impossible due to the pain affecting your daily activities, then it is time to be evaluated and treated.  Treatment options include anti-inflammatory medications, physical therapy, injections, and eventually surgery if it is necessary.  Dr. Waddell's goal is to get each patient back to full function and pain free and while exhausting non-operative treatments before surgery.