The majority of knee problems relate to either meniscus tears or osteoarthritis. Meniscus tears can often be traced to a definitive injury, but sometimes simply working in a crouching position or getting up from kneeling can cause the tear. In patients under 60, meniscus tears are most problematic when they cause mechanical symptoms such as catching, locking, or giving way of the knee. Swelling is often associated. Joint line tenderness on the affected side is typical. An MRI will usually confirm the diagnosis, or suggest other pathology. If the mechanical symptoms persist, referral for consideration of arthroscopy is indicated.
Osteoarthritis can cause aching pain, swelling, stiffness and disability with prolonged weight bearing activities and in more advanced cases even at rest. Symptoms will usually at least initially responded to conservative treatment such as analgesics, leg conditioning exercise, and maintenance of a healthy weight. Failing this, unloader bracing or injections can be tried, although patients are often looking for surgical solutions by this point. Older patients should be encouraged to try a cane, and to stay as active as possible. If xrays show moderate to severe OA , and especially if patients are having symptoms at rest, referral for consideration of surgical treatment is appropriate.
Osteoarthritis and meniscus tears can of course coexist, but if the OA is significant, especially in those over 60, a meniscus tear is usually of little importance and will not likely be significantly aided by arthroscopy. Therefore, with knee pain in those over 60, especially chronic pain and without significant mechanical symptoms such as locking or instability, an MRI is rarely beneficial to direct treatment. Even if a degenerative meniscus tear is incidentally identified the OA is likely of greater importance, and the time and expense of MRI is wasted. It is therefore sufficient to order a knee xray only. Too many MRIs are performed in patients who have primarily OA and have not yet had a simple xray.
Standing and stress view xrays are quite helpful in characterizing knee OA, both to determine the degree of the condition as well as potential appropriateness for a partial knee replacement. These specific xrays are usually performed in a standardized fashion at the Brandon Clinic at the initial visit.
If a ligament tear is suspected, especially an ACL tear, an MRI is very helpful and should be ordered when the injury is suspected. If this does demonstrate an ACL tear, an ACL brace can be ordered and physiotherapy initiated. In active patients under 40, who may be interested in ACL reconstruction surgery, a referral for consideration of surgery is recommended. If these patients are quite debilitated by the injury, it is helpful to refer them even before an the MRI is completed or a result is available. Older patients with an ACL tear should initially be treated conservatively with a brace and physiotherapy.
Again, in ACL patients with associated significant OA, especially in chronic cases and those over 50, the OA will usually take precedence over the ligament tear, and be treated as such. ACL bracing for vigorous activities can be quite helpful in this situation, although if OA pain is more of a problem than instability, unloader bracing on the side of the OA (usually medial) is preferable to an ACL brace.
Patellar problems range from patellofemoral syndrome (or anterior knee pain), common especially in young women, to patellar instability, either with an acute dislocation or recurrent subluxations or instability. Physiotherapy and patellar bracing are the mainstay of treatment in these conditions, and if unsuccessful surgery may be considered. Patellar chondromalacia or osteoarthritis are often chronic, and again may benefit from surgery if non-operative measures including aggressive quadriceps strengthening are inadequate.