Knee and ankle pain causes

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Knee pain is a very common complaint, and there are many causes.

It’s critical that an accurate diagnosis is made so that appropriate treatment can be directed at the cause.

Examination of the anatomy may help in the understanding of knee pain. The joint is made up of three bones: the femur (thigh bone), the tibia (shin bone), and the patella (knee cap). The surfaces of these bones within the joint are covered with articular cartilage. This important surface allows the bones to smoothly glide against each other without causing damage to the bone. A semi-circular piece of tissue called the meniscus sits between the articular cartilage surfaces of the bone to distribute weight and to improve the stability of the joint.There is one meniscus on the medial side and one on the lateral side.

Arthritis is probably the most common cause of knee pain. Osteoarthritis is the most common type of knee arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage is worn away by knee arthritis, bare bone is exposed within the joint.

Osteoarthritis typically affects patients over 50 years of age. It is more common in patients who are overweight, and weight loss tends to reduce the symptoms associated with knee arthritis. There is also a genetic predisposition of this condition, meaning knee arthritis tends to run in families. Other factors that can contribute to developing knee arthritis include trauma to the knee, meniscus tears or ligament damage, and fractures to the bone around the joint.

Osteoarthritis symptoms tend to progress as the condition worsens.

Often patients report good months and bad months or symptom changes with weather changes.

The most common symptoms of osteoarthritis knee arthritis are:

• Pain with activities
• Limited range of motion
• Stiffness of the knee
• Swelling of the joint
• Tenderness along the joint
• A feeling the joint may "give way"
• Deformity of the joint (knock-knees or bow-legs)

Evaluation of a patient with knee arthritis should begin with a physical examination and X-Rays. These can serve as a baseline to evaluate later examinations and determine progression of the condition.

Other types of arthritis may affect the knees. These include rheumatoid arthritis, psoriatic arthritis, Reiter’s disease, Lyme disease, gout, and pseudogout.

Treatment of knee arthritis starts with basic steps, and progresses to more involved, possibly including surgery. Not all treatments are appropriate in every patient. Also, the type of treatment will also vary depending on the type of arthritis.

Here are some of the treatments that work in general.

Weight loss is probably one of the most important treatments. The less weight the joint has to carry, the less painful activities will be. Also, fat cells (called "adipocytes") produce leptins, which are proteins that promote inflammation. Another reason to lose weight.

Limiting certain activities may be necessary, and learning new exercise methods may be helpful. Aquatic exercise, since it is non-weight-bearing, is an excellent option for patients who have difficulty exercising.

Use of a cane or a single crutch in the hand opposite the affected knee will help decrease the demand placed on the arthritic joint.

Strengthening of the muscles around the knee joint may help decrease the burden on the knee. Preventing atrophy of the muscles is an important part of maintaining functional use of the knee.

Anti-inflammatory pain medications (NSAIDs) are prescription and nonprescription drugs that help treat pain and inflammation.

Corticosteroid (cortisone) injections may help decrease inflammation and reduce pain within a joint.

Viscosupplement injections which are injections of lubricant may be effective against pain in some patients with knee arthritis and may delay the need for knee replacement surgery.

Glucosamine/chondroitin supplements appear to be safe and effective for treatment of knee arthritis.

Knee arthroscopy may benefit certain people with arthritis.

The use of autologous stem cells (a patient's own stem cells), while still in its infancy appears promising as a method of regenerating cartilage.

While most patients are not good candidates for knee osteotomy (removing a wedge of bone to realign the knee), this alternative to knee replacement can be effective for young patients with limited arthritis.

Total knee replacement surgery is a procedure where the cartilage is removed and a metal and plastic implant is placed in the knee.

Unicompartmental knee replacement (partial knee replacement) is replacement of one part of the knee. It is a surgical option for the treatment of limited knee arthritis.

Another cause of knee pain is meniscal tear.

These menisci function to distribute body weight across the knee joint.

Both the covering of the bone within the joint and the meniscus are made of cartilage. The covering cartilage is hyaline cartilage. The menisci are fibrocartilage. When people talk about a cartilage tear, they are talking about a meniscus tear (fibrocartilage). When people talk about arthritis and wear of cartilage, they are talking most often about the articular cartilage (hyaline cartilage) on the ends of the bone.

The most common causes of a meniscus tear are traumatic injury (often seen in athletes) and degenerative processes (seen in older patients who have more older, more fragile, cartilage).

It is not uncommon for the meniscus tear to occur along with injuries to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL)-these three problems occurring together are known as the "unhappy triad," which is seen in sports such as football when the player is hit on the outside of the knee.

Individuals who experience a meniscus tear usually experience pain and swelling as their primary symptoms. Another common complaint is joint locking, or the inability to completely straighten the joint. This is due to a piece of the torn cartilage interrupting the joint mechanism of the knee.

The most common symptoms of a meniscus tear are:

• Knee pain
• Swelling of the knee
• Tenderness when pressing on the meniscus
• Popping or clicking within the knee
• Limited motion of the knee joint

Most knee injury can initially be treated acutely with ice packs, rest, and immobilization. These simple measures will help to decrease swelling and pain in the joint.

The next step is to determine whether or not surgery is necessary for a meniscus tear.

It is only when the meniscus tear becomes symptomatic, and interferes with activities, that surgery to treat the meniscus tear should be considered.

With a meniscus tear (torn cartilage) in the knee, the shock absorbing capacity of the joint is threatened. Because of this, there is an increased risk of developing damage to the articular cartilage surface of the knee joint bones.

Chondromalacia patella is a common cause of anterior knee pain. Chondromalacia is due to an irritation of the undersurface of the kneecap. The undersurface of the kneecap, or patella, is covered with a layer of smooth cartilage. This cartilage is supposed to glide smoothly during bending of the joint. However, in some individuals, the kneecap tends to rub against one side of the knee joint, and the cartilage surface become irritated, and knee pain results.

It often strikes young, otherwise healthy, athletic individuals. Women are more commonly affected with chondromalacia.

The treatment of chondromalacia consists of resting the knee and adhering to a proper physical therapy program. Avoiding painful activities that irritate the knee for several weeks, followed by a gradual return to activity is important.

One common misalignment issue that leads to chondromalacia is abnormal tracking of the patella (tracking is simply the movement of the patella as the knee moves) caused by too much lateral tension. For this problem, a procedure known as a lateral release can be performed. The lateral release involves cutting the tight lateral ligaments to allow for normal position and tracking of the patella.

Prepatellar bursitis is a common cause of swelling and pain above the kneecap. It is sometimes referred to as "housemaid's knee". The name comes from its association with individuals whose work necessitates kneeling for extended periods of time. Prepatellar bursitis is common in professions such as carpet layers and gardeners.

The symptoms of prepatellar bursitis or knee bursitis are a swelling over the kneecap which can cause limited range of motion of the joint. The swelling is within the bursa, not the knee joint itself. Symptoms of prepatellar bursitis are usually aggravated by kneeling, and relieve when sitting still.

Treatment of prepatellar bursitis begins with avoidance of the aggravating activity. In some individuals, drainage or excision of the bursa may be indicated. In cases of infection, it is important that antibiotics are also administered.

Tracking abnormalities of the patella can cause knee pain. The kneecap slides up and down a groove on the end of the femur as the knee bends. This groove is called the patellofemoral articulation.

Also called patellar subluxation, patients who experience an unstable kneecap have a patella that does not track evenly within its groove on the femur. Most commonly, the tracking problem causes discomfort with activity, and pain over the edges of the kneecap.

One of the most common problems involving the knee joint is an anterior cruciate ligament tear. The anterior cruciate ligament (also called the ACL) is one of four ligaments that are critical to the stability of the knee joint. A ligament is made of tough fibrous material and functions to control excessive motion by limiting joint mobility. Of the four major ligaments of the knee, the ACL injury is the most common knee ligament injury.

The ACL prevents the tibia from sliding too far forward.

When an ACL injury occurs, the knee becomes less stable. The ACL injury is a problem because this instability can make sudden, pivoting movements difficult, and it may make the knee more prone to developing arthritis and cartilage tears.

Patients may be able to function in their normal daily activities without a normal ACL, but high-demand sports may prove difficult.

Signs of an ACL tear:

• Sudden giving way of the knee
• Hearing a 'pop' at the time of injury
• Sudden swelling of the knee joint
• Pain in the knee when walking

The presence of an ACL tear is suspected whenever a patient has an injury to their knee. Knee instability can be assessed by specific maneuvers performed by the physician. These maneuvers test the function of the ligament to determine if an ACL tear is present.

Ankle Pain

Strains and sprains are the most common ankle injuries. A strain is the stretching or tearing of a muscle or tendon. A sprain is the stretching or tearing of ligaments. Ligaments connect bone to bone. In most cases of ankle sprain, the ankle is twisted inward, causing tiny tears in the ligaments. This makes the ankle somewhat unstable. The tearing leads to swelling and bruising, making it difficult to bear weight on the joint.

Once an ankle is sprained, the injury may take a few weeks to many months to fully heal. Often, the injured ankle remains a little weaker and less stable than the uninjured one. A proper recovery program can prevent this problem.

Other structures in the ankle that can be damaged and cause pain are tendons (which join muscles to bone), cartilage (which cushions joints), and blood vessels. Adjacent areas can cause pain to be referred to (felt in) the ankle -- these include the foot, lower leg, knee, and even hip.

Most ankle sprains can be successfully treated with a conservative regimen of rest, ice, bracing, and functional rehabilitation.

An ankle support like an aircast can help.

For swelling, keep the foot elevated above the level of the heart, even while sleeping. Ice the area right away. Apply ice for 10-15 minutes every hour for the first day. Then, every 3-4 hours for 2 more days.

Try acetaminophen or ibuprofen for pain and swelling.

Even after the pain subsides, a person will need to keep pressure off of it for up to 10 days for a mild sprain and up to 5 weeks for a more severe sprain.

Once the person has healed adequately, they can start exercises to strengthen the ankle and avoid injury in the future. One should not begin these exercises until a health care professional tells the patient it is safe to start. One exercise, for example, involves balancing on the healing foot and hopping.

More about ankle sprains and pains...

Most injuries to any of these structures can be treated conservatively. Even with optimal treatment, however, a few patients will continue to have ankle pain 6 weeks or more after a sprain.

For arthritis of the ankle, one should take medication exactly as prescribed. Sometimes injections of glucocorticoid are needed. When the pain and swelling start to decrease, one can gently begin to exercise the joint again. Swimming is good, followed by stretching. Walking can be added later. Exercises can be done several times a day; but they should not be overdone.

Osteoarthritis of the ankle has been treated successfully with autologous stem cells.

The Achilles tendon is a large, strong band that attaches the calf muscle to the heel. Underneath the Achilles tendon are bursas that may also become inflamed. Bursas are fluid-filled sacs that cushion movement within a joint.

Symptoms of Achilles tendinitis include pain in the lower calf and back of the heel. Occasionally, with an improper warm-up or sudden movement, the Achilles tendon can tear or even rupture. Bursitis usually causes inflammation of a bursa at the back of the ankle, along with pain similar to that of tendinitis.

Common causes of tendinitis and bursitis in the ankle include tight calf muscles, overuse, sudden stress from a quick movement, and repeated motion, such as running. Shoes are often the culprit. Switching from high heels or cowboy boots to flat shoes, or wearing shoes that fit poorly or provide inadequate support and cushioning, can also inflame tendons and bursas.

Gout often begins in the big toe, but it may move to the ankle and knee. Symptoms of gout may show up in a joint. They include:

• Sudden pain or extreme tenderness
• Swelling
• Redness

Reflex sympathetic dystrophy may follow foot and ankle trauma and will be manifested by severe pain of a neurogenic variety along with skin discoloration and temperature change. Pain alleviated by a sympathetic block is the key to diagnosis. We refer patients who have reflex sympathetic dystrophy to a pain management specialist.

Fractures that may be difficult to see on plain radiographs may rarely occur in other tarsal bones. We have encountered patients who have fractures of the calcaneus and talus. In these cases, an MRI or computed tomography scan may be essential for diagnosis.

Patients with long-standing rheumatoid arthritis are at risk for developing a condition called hind-foot valgus where the heel turns out. This places a tremendous amount of stress on the medial portion of the ankle. This leads to inflammation and damage involving the posterior tibial tendon. In some cases the tendon will rupture.

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