Tricky Business Series: Knees

Not all sports injuries are straight-forward, occasionally they can be quite tricky to repair. Luckily there are highly experienced consultants such as Dr Catherine Spencer-Smith, on hand to help.

Dr Catherine Spencer-Smith concludes her mini-series on troublesome sports injuries, looking at tricky knee injuries.  If you find this post of interest, then take a look at her previous posts in the Tricky Business series; Tricky Shoulder, Tricky Groin Injuries and Tricky Ankles 

The knee is much more than just a large hinge: It actually permits a little rotation, enabling us to pivot quickly on the foot. It consists of a joint between the femur and the tibia (the tibiofemoral joint), as well as the patellofemoral joint, (where the knee cap articulates with the femur at the front of the knee). The articular surfaces are covered in shiny articular cartilage, and the two menisci (made of fibro cartilage) help distribute pressure forces through the knee. The knee’s stability relies on static structures (such as the cruciate and collateral ligaments), as well as muscular balance throughout the lower limb.

When assessing a knee problem, we need to consider whether a specific injurious event occurred, and the mechanism of the ‘twist’ or fall. We need to understand whether the knee swelled, whether the knee feels unstable or mechanically locks, and where and how the pain is affecting the patient.

Some injuries occur with surprisingly little force (e.g. a twist on a planted foot can result in the tear of a meniscus, or even an anterior cruciate ligament rupture).  Other injuries are mistakenly thought to be ligament ‘sprains’ , when in fact, they are more likely to be due to damage to a meniscus or articular cartilage.  Some knee problems occur as a result of ‘wear’ or overuse.

For example: Pain felt below the knee cap may be due to tendinopathy of the patellar tendon, (especially if it ‘warms up’ with exercise). Pain felt with the sliding motion of the knee cap (especially when associated with a grating sensation), may be due to articular cartilage damage in the patellofemoral joint, and in runners, pain felt on the lateral (outside) part of the knee, is commonly due to iliotibial band friction syndrome.

Some runners tend to hyperextend a little at the knee when they strike the ground, which can ‘nip’ a soft tissue structure called the fat pad.  Confusingly, knee pain may actually be referred from the hip or the lumbar spine, or may be due to a stress/bone overload problem (e.g.  in endurance athletes).

The knee’s action is heavily influenced by motion at the hip, foot and ankle, as well as muscular control occurring at many levels in the body. Our experience as sports doctors is that often these biomechanical and conditioning problems may go unnoticed and unresolved; indeed many patients have been through the dissatisfying experience of being told that their knee MRI scan is ‘normal’ and therefore no further treatment was offered.

It’s therefore unsurprising that some people struggle on with poor self-treatment. A thorough assessment and an accurate diagnosis, can pin point the underlying cause in such cases (e.g. inadequate gluteal strength resulting poor loading patterns through the knee). It is worth remembering that up to 90% of injuries do not require surgery. Many conditions will settle well with exercise rehabilitation (e.g.with a physiotherapist, osteopath, or strength and conditioning coach), soft tissue treatments (including ultra-sound guided injections), and sometimes biomechanical adjustments (e.g. the use of orthotics in sports podiatry). Persistent pain or swelling in the knee should always be a ‘call to action’.

Prompt assessment is swiftest way to get back to comfortable activity, and can prevent long-term secondary damage.

If you would like to make a referral or an appointment to see Dr Catherine Spencer-Smith, please call the Enquiry Helpline on 020 7483 5148