An injury or some traumatic occurrence, perhaps minor, can be the precipitating event which kicks the knee joint into a painful state. Even a small injury can cause the joint to swell and the knee can react in complex and negative ways to the presence of minor levels of fluid in the joint. Trauma causes the synovial lining to secrete synovial fluid and this is contained inside the capsule of the joint, continual movement irritating the joint by stretching of the capsule. A swollen knee is typically held at an angle of about thirty degrees as this is the most comfy, loose position for the joint.

Once the knee is held bent for a while this can develop into a flexion contracture, a small permanent bend in the joint. The part of the quadriceps muscle which performs the screwing home movement of the knee lock is then unable to perform its function and starts to atrophy. The weakness which develops in this muscle makes it gradually more difficult to straighten the knee in activity, adding to the abnormal stresses placed on the knee.

Chondromalacia patellae is a commonly diagnosed problem with the cartilage on the underside of the kneecap. Normally the kneecap sits lightly against the groove on the front of the femur and is only strongly pressed against it in loaded movements such as getting up from a chair or descending stairs. If the knee tightens and loses some of its accessory movements then the patella can become more tightly compressed against the femur. This can set up a frictional process between the two bony areas, particularly if there is bow leg or knock knee, where the tibia is rotated abnormally or where one leg is longer than the other.

The joint surface of the kneecap can develop increased irritability and this limits the willingness to keep a bent knee for any time, preferring to straighten it to reduce the force. As increased forces bear on the kneecap, the articular cartilage lining it changes and becomes lined and fluffy instead of hard and smooth. Further irritation is provided by increased swelling in response to the joint surface changes, with grooves developing in the cartilage as it worsens. Subluxation of the patella, where it moves out of its groove to some degree, can occur with sudden movements such as turning and twisting.

If the patella subluxes this is a sudden and extremely painful event which traumatises the surfaces of the joint and can result in considerable pain and swelling of the knee. The kneecap usually subluxes or dislocates to the outside and this stretches the tissues which support the knee on the inner side, making them weaker and allowing the abnormal patellar movements to occur more commonly. In severe cases the patella can dislocate repeatedly which can be disabling and various operations are used to improve matters. The tissues can be tightened up on the medial side, known as reefing, to attempt to hold the kneecap more over to the inside.

After an attempt at minor interventions has not been successful then the surgeon can progress to tibial tubercle transposition, the moving of the bony prominence on the upper shin bone towards the inner side of the knee. This brings the line of pull of the quadriceps muscles into a more inwards line and draws the kneecap in away from the side where the pressure is greatest. Investigation by arthroscopy can show an appearance of fissures and softened cartilage in worse cases of damage. Wasting of the quadriceps muscle can occur in response to the inflammation and pain of this process.

As the quadriceps muscle wastes and become weaker the knee is less and less well supported, and the patella cartilage damage makes particular activities painful such as descending slopes and stairs, which place higher forces through the patello-femoral joint. Going downhill involves the quadriceps controlling the movement as the muscle lengthens rather than the more obvious shortening mechanism we are more familiar with.

A surgeon can debride the back of the joint via arthroscopy, surgically cleaning up rough areas and debris, but results of this procedure are not predictable. Manual pressures or exercises to press the surfaces together in an attempt at smoothing them can be performed by physiotherapists but this is a therapeutic technique with little support from evidence.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Cambridge. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The menisci (often called cartilages) and the main joint surfaces of the knee can be made more vulnerable to injury and damage if knee control is not good enough to prevent unplanned joint movements. Meniscal function is partly to control movement of the femoral condyles into particular paths, centring them on the upper shin bone plateau. Without the guiding help the large and strong condyles can catch the edges of the menisci as they roll across the tibial plateau and so cause tears or other damage to the menisci.

The types of damage pattern which can occur in the menisci vary and include the development of tears, splits and bites out of the edge. A “bucket handle tear” can develop if the condyle causes a circumferential split in the meniscus whilst the ends of the tear remain attached to the rest of the meniscus. An unplanned movement such as twisting and turning can damage a meniscus and dislodge a part of it into the joint as a loose body. This can move around inside the knee and jam between the surfaces of the joint, causing sharp pain and a giving way of the knee when it is weight bearing.

As the cartilage continues to erode it can guide the femoral condyles less and less, perhaps increasing the forces which are transmitted across from the femoral condyles to the tibial surface. As the surfaces suffer increased forces they can also degenerate, leading the osteoarthritic changes within the knee. Before modern arthroscopic management a common procedure was to remove the meniscus entirely if it was giving trouble, leading to osteoarthritic changes some years later. Any significant problem with a knee leads to wasting of the medial part of the quadriceps muscle and much effort is expended in strengthening this area.

The ranges of movement of the joint and normal accessory movements need to be restored for the medial quadriceps to respond to strengthening work. Knee extension needs to be full for the medial quadriceps to exert their full and functional force and the accessory movements contribute to the necessary play within the joint. If the full extension is not returned then the exercise to strengthen the muscles will likely be in vain. The development of modern arthroscopy techniques has allowed internal inspection of the joint and the ability to do the minimal intervention to achieve the required treatment goal.

Osteoarthritis is one of the commonest joint conditions in the world, affecting hundreds of millions of people and occurring almost universally to some degree in elderly people. A family history, meniscal surgery, joint trauma or ligament injury can all predispose the joint to later osteoarthritis. Damage to and stretching of either the medial or lateral ligaments can cause some sloppiness of the control of movement in the knee, causing increased forces to be generated across the joint and contribute towards articular surface breakdown. Shearing movements, causing a lateral stress as the joints are in contact, exert high forces on the surfaces.

The knee can start to develop a grating or clicking as it ages with small degrees of degeneration and is only painful if kept in one position for excessive periods. The joint capsule can become tighter if we do not perform the strong movements any longer which stress the joint to the ends of its ranges. This can increase joint compression which increases the stresses across the joint surfaces and make the joint more likely to be injured during stressful movements. As the process continues the cartilage wears down and the underlying bone, which normally has some elasticity, becomes denser and harder.

An arthritic knee can be enlarged, swollen, hot and painful with limited range of movement, crepitus on motion and a degree of disability. Pain and swelling can go through repeated cycles and gradually become worse as the joint deteriorates. Walking may be limited and the knee pain can disturb sleep due to the difficult in maintaining a position. As the inside of the joint can become very tender it does not tolerate pressure from another knee or the gapping pressure which can occur when we lie on our sides. A pillow between the knees is typically required.

Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Nottingham visit his website.

Small movements which allow a glide and a slide inside a joint are essential for the normal use of the joint but cannot be done in isolation, occurring with other movements. These are called accessory movements and their presence is vital to joint function, a reduction in available range or a pain problem resulting if they are lost or reduced. The hip is a deep joint with significant stability so the accessory movements are rather subtle, with the main one being compression and distraction, the pushing in to and pulling out of the ball from the socket.

The cycles of compression and relaxation which occur with weight bearing and gait are essential to the health and nutrition of cartilage. As the cartilage is compressed it gives to some extent even though it is quite dense and once this is released it reverts to normal shape, squeezing the fluid out of it under pressure and then sucking it back in as force is removed. This sets up a pumping action of fluid up from within the cartilage and underlying bone, providing an essential fluid replacement mechanism to keep cartilage healthy.

The typical mechanical stresses through the joints stimulate the production of new cartilage cells, with the on-off stresses being important to counter the high forces involved when we put our heels down in gait. Bigger movements in larger amplitudes may encourage cartilage growth whilst absence of stresses or sustained loads may impede synthesis of cartilage. Cartilage breakdown may be encouraged by high bodyweight, static loading for long periods or by reducing loads such as by use of a stick.

Resting a joint when it is painful is not a clearly positive strategy. Pain may be reduced when resting but the mechanisms which encourage regrowth of cartilage are not stimulated and the joint capsule may stiffen and reduce the available range of movement at the joint. This may increase the compressive forces in the joint and produce more pain. Whilst painful joints do need respect, in general arthritic joints are worse being still and better being kept moving about. The ability to achieve a rhythmical cycle of gait is very beneficial for the movements and the blood supply of the upper femoral structures.

The ligamentum teres, a band like structure running from the head of the femur to the socket, has blood vessels which may be affected by the cycle of gait which produces a effect of pumping fluid through. This may allow better blood supply to the head of the femur and keep the bone healthy. To maintain the density and normal composition of the bone in the upper femur it is important for this area to be subject to normal forces such as walking. Use of a walking aid or resting in bed can cause loss of bone density and mineralisation, with the bone becoming less flexible and less resistant to jars and strains.

Western individuals normally take advantage of only a small proportion of the large ranges of movement which the hip possesses. The repeated nature of walking only occurs in small ranges and we rarely go over 90 degrees flexion when we are sitting. As time goes on we push our hips less and less towards the ends of their movement, allowing loss of motion. Keeping the full ranges of movement available is beneficial to hips as is pushing them as far as they will go from time to time. In the east many people squat, even for ironing, and may have lower incidence of hip arthritis than western populations.

A lack of use in the end ranges of a joint can mean the joint capsule will exhibit some tightening and in this way increase the compressive forces suffered by the head. Extension of the hip can be particularly affected by a difference in leg length. The longer leg in standing will tend to bend slightly at the hip and knee to keep the head level for the eyes to function best. This compensation can lead to stiffness developing with some loss of hip and knee extension as the hip develops a fixed flexion deformity.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Bolton visit his website.

The mechanical connection between the legs and the mass of the trunk occurs at the hip joints with their large socket and ball. The hip socket or acetabulum is a deep rounded structure with a rim of cartilage which closely holds the head of the femur, the large ball structure at the top of the thigh bone. As befits a joint where large forces are applied, the hip is stable, deep and has strong stabilising features. To permit fluid movement under considerable bodily loads the hip surfaces are covered with articular cartilage which confers almost friction-free motion under these loads. This is essential to the hip and the thickest cartilage is where the greatest forces are applied.

Surrounding the head, socket and neck is the capsule of the hip joint which runs from the lip of the socket down over the head and neck to the base of the neck. It is a fibrous bag lined by synovial membrane which secretes the lubricating and nutritional fluid for the cartilage, and is strengthened by denser bands of tissue, the major hip ligaments. The hip is designed so that the femur can fit into the socket in the pelvis at an appropriate angle for weight bearing and exerting mechanical forces. The femur comes up to the hip area and then the neck turns inwards at an angle of 125 degrees to access the pelvic socket.

Inside the hip the bony anatomy of the supporting struts or trabeculae are also mechanically aligned along the lines of most force, responding to the requirements of bodily motion and bearing weight. The densest areas reinforce the parts suffering the highest stresses. If the hip copes with these stresses by developing strengthened areas it also has areas of less strength which can become relevant in older people as they fall and suffer fractured necks of femur across these areas. As the number of older people dying after this fracture is relatively high, this matter is of concern.

The hip is designed to perform locomotion of the body and to stand and manage the body weight through the legs. To perform these actions the hip joints have very strong muscles to stabilise them and move them and the body in some cases quickly and with force. The hip abductors, adductors and gluteal muscles are all major stabilisers and movers of the joint. The abductors play a large part in the sideways stability of the pelvis and the gluteals, the body’s most powerful muscles, move the body weight around.

The articular surfaces of the hip are subject to very high mechanical forces, much greater than the body weight in activities such as running, jumping and climbing stairs. To cope with this the articular cartilage is thick on the most exposed areas, although the nutritional supply to cartilage mostly relies on synovial fluid and some from the underlying bone. New cartilage is slowly formed from below as some is worn off at the top by activity, and the balance between these two actions is critical to the health of the joint.

The synovial membrane lines the capsule of the hip and performs the secretion of small amounts of synovial fluid. This fluid is not present in large amounts but is thought to lubricate the movements of the joint, help particles of wear be absorbed to prevent a grinding paste being developed and spread mechanical loads throughout the joint. If the joint is under great load, the synovial membrane can respond to the cyclical stresses by increasing its secretion rate to protect the joint and lubricate it during periods of high activity.

Any disturbance in the available movements of the hip will have consequences on its most important function, gait. An even stride length and balanced gait pattern is essential for normal daily function and to the health of the hip joints themselves. We have a typical and restricted pattern of joint movement when we walk but the movement which often becomes limited first is extension, the ability to take the leg behind as the other leg strides forward. At around 20 degrees there is much less hip extension that hip flexion, the ability to take the thigh towards the chest, which is about 130 degrees.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Exeter, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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