| |
Young or old, athletes or sedentary workers
– most people get knee pain at some time or other.
An old lady went crying to the doctor: ‘I cannot
walk, even walking in the house hurts me. I do not want
to be crippled and dependent for little things on my
children.’ Old age and knee pain are almost
synonymous.
A young footballer trying to kick the ball, fell down,
but rose up and collecting all his courage, continued
with the game. The next day, he had a big swelling over
the knee and a lot of pain. He hobbled to the clinic with
the help of a friend, was treated and asked to spend a
few days in bed. For several weeks he limped in great
discomfort. The pain and swelling gradually subsided. A
few months later he complained of pain in the knee
whenever he exerted it. It would swell up for a day or
two after the strain and the swelling would subside
completely a few days later. If the legs were stretched
to their full, they hurt, and sometimes he found it
difficult to bend the knee joints. Rotational movements
at the knee also hurt. All this indicated that the
ligaments had been strained during the injury and
adhesions had formed during recovery. Due to the pain,
the knee was not being used to its full extent, and
following this, wasting of the thigh muscles had started,
further aggravating the pain.
Weak muscles are not able to give full support to the
knee and all the strain falls upon the ligaments. What is
the treatment for such a knee? The answer lies in
breaking the adhesions by manipulative reduction: this
will bring back free and painless movement. The patient
should be advised to do exercises for the quadriceps and
rebuild his thigh muscles to give the knee full support.
Strong thigh muscles take off the strain from the
ligaments and the pain disappears completely. If the
ligaments undergo a long stress and are stretched for
long, they start aching. Muscles can remain contracted
for any length of time and they will not ache.
The knee is the largest joint in the body, and has the
function of supporting the entire body weight. One of the
disadvantages of the knee joint is that it does not heal
quickly. For faster healing any joint should be given
proper rest. This is not possible for the knee joint. As
you get up, stand and walk, you put all the weight of the
body on your knees and irritate the healing joint.
However the knee is a joint where a more exact diagnosis
can be made than in any other joint because the greater
part of the joint and its ligaments and tendons can be
felt by the hands. Sometimes when diagnosis is not
possible in a middle-aged person, the cause of pain may
be a cartilagenous loose body inside the joint. Cartilage
cannot be seen in an X-ray picture. Sometimes bone
margins can flake off as loose bodies and be seen in the
X-ray, but most of the time they are not the cause of
pain as they remain attached to the synovial membrane of
the joint capsule and do not cause any interference in
movement.
The pain is often localised in the joint itself. An
impacted loose body in the joint may cause pain, thus
complicating an existent case of osteoarthritis. The pain
may be up in the thigh and down in the leg but the
patient quite clearly indicates that the symptoms
originate from the knee. Pain in front of the knee can
also be caused by a lesion in the lower back. Any
mechanical disturbance at the third lumbar nerve may
cause pain in the knee. In such cases a patient
complaints of vague pain in the whole knee and cannot
pin-point the exact spot. He may complain of pain above
the knee cap or in front, or in the inner aspect of the
thigh upto the groin. The hip joint, when at fault, can
also cause pain in the knee. Examination of the knee in
such cases helps in establishing the diagnosis.
Pain is common among bow-legged persons due to the strain
on certain ligaments rather than because of
osteoarthritis. A few cases of the knee relate to
hypertrophy of the joint wherein the knee is swollen with
limitation of movement in all directions, and more so on
flexion than extension. Extension may be limited top 5-10
, whereas flexion may be limited to 60-90 . Diagnosis
A detailed history
of the patient must be taken including his age,
occupation, how the pain, whether he suffered an injury,
and if so, in what position. Enquiries must be made about
how he was standing, how he twisted his knee, whether
there was any injury at all. Did the knee give way? Did
it lock, and if so, at that time, was the leg straight or
bent? If it was locked, how did he unlock it? Was the
pain located all over? Did the pain shift from one place
to another? Did the knee swell, and if so, how quickly?
For how long was the patient disabled? Was he still
experiencing sudden twinges, feeling clicks or hearing
grating sounds in the knee?
The diagnosis has to be clear before treatment is
started, the X-rays and laboratory tests confirming the
diagnosis. However, the following conditions must also be
excluded before manipulating a joint: a tubercular knee,
gonorrheal or septic arthritis, gout, rheumatoid
arthritis, active infective arthritis and other possible
ailments.
Treatment
Manipulative
reduction helps in complete recovery in the shortest
period. Manipulation helps to achieve full movement at
the knee joint. Realignment of the joint bones takes off
all the strain from the ligaments, and they recover
completely. Manipulation can be done on the young and the
old. Techniques and manoeuvres are selected according to
the needs of the patient. All cases of advanced
osteoarthritis, chronic ligamentous injury and
post-traumatic adhesion can be manipulated. A gradual
improvement in the range of movement and reduction in the
pain is seen.
Quadriceps
Drill
This is an
important exercise to be undertaken by patients suffering
from pain in the knees. Though this exercise is very
commonly advocated to patients by medical practitioners,
necessary stress is not laid on its usefulness and
importance. Also, it should not be done so strenuously so
as to tire the patient before it can be effective.
The girth of the thigh should be measured and the patient
should be educated about the wasting and weakness
of his muscles. This can be measured by making a mark
three or four inches above the upper margin of the knee
cap and girth of both the thighs measured and compared in
both legs.
The patient must be told that he has to regain the normal
girth and strength and that this will take time. It
cannot be achieved in a week or a month; it will take a
couple of months or even a year. At each visit the girth
of the thigh must be measured and noted so as to make the
patient more conscious of this. The quadriceps drill must
be done in the following manner: The patient is asked to
lie on his back keeping his leg straight. He is asked to
contract and tighten the thigh muscles without bending
the knee. As he contracts his thigh muscles, the knee cap
is seen moving up and down. This has to be done for 2-3
minutes at a time and repeated during the day as often as
possible, preferably 20 times day. This simple exercise
can be done while standing or sitting. To do this while
sitting, one has to place oneself on the edge of the
chair, straighten the leg and keep the back of the heel
on the ground. It can then be done comfortably. The
patient gets into the habit of doing this exercise
without any effort in seven to ten days’ time. It
becomes as effortless as cycling or driving. It is so
convenient that it can be done in the office, at home, or
even while waiting for the bus. This exercise starts
showing results in three to four weeks.
Weight
Reduction
All the body
weight has to be carried by the knee joint. A reduction
in weight relieves it of the pressure to some extent. The
medical practitioner asks the patients to walk as much as
they can and keep their joints mobile, so that they do
not get jammed. In my opinion, movement is desirable, but
not the strain of walking when the pain is severe. As the
pain decreases, the patient can undertake further
activity.
The strain of standing can be taken off from the knee if
the patient is asked to bend the painful knee and out it
on a chair or stool and stand on the painless leg, for
instance, while washing at the basin or cleaning
utensils. This will protect the painful knee from
excessive strain and give it rest so as to hasten the
recovery period.
Case Histories
- A forty-year-old man
in the tea business was involved in a car
accident and had pain in his left knee. It
subsided after taking shortwave diathermy and
doing knee exercises for about a month. However
the pain in the knee continued to come and go,
and gradually increased. For one and a half
months it became almost continuous. It was
painful for the patient to get up after sitting
on the ground. The pain became worse and reached
the thigh. Due to this and lack of activity, he
began gaining weight and added six kilograms to
his weight. The X-ray of the damaged knee showed
osteoarthritis. Manipulative treatment of the
left knee was started. The knee was strapped
following manipulation. The patient was asked to
do the quadriceps drill for forty minutes a day.
He began showing signs of improvement following
the first treatment and the pain became much less
by the end of the third week. He recovered in two
months, and was advised to continue the exercise
for another month.
- A 65-year-old lady
had pain in the left knee for three years. Later
on the pain started in the right knee too, and
was accompanied by pain in the lower back with
numbness and tingling. She consulted an
orthopaedic surgeon and five injections of
hydrocortisone were given inside the knee joint.
These helped her and she felt better. After two
months however, the pain started all over again
and she went to her village and underwent massage
for two and a half months. She did get relief but
the pain persisted.
When she came to me, the X-rays of her lumbar
spine and both knees indicated that she suffered
from osteoarthritis. The lumbo-sacral spine
showed a slipped disc with osteoarthritic
changes.
After manipulative treatment for the lumbar spine
and both knee joints, she was advised to do the
quadriceps exercise at home every day. She
started showing improvement from the second week.
The pain in her lower back and the tingling
sensation in the left leg subsided in six weeks
and her knees showed considerable improvement.
She made complete recovery in three months.
- A
fifty-seven-year-old lady, obese but tall, had a
job which compelled her to walk long distances.
She began experiencing pain in the left knee
though she had not suffered any injury. She felt
more pain and stiffness when she tried to get up
after sitting for a while. The pain became severe
for ten days. She took anti-inflammatory drugs
but these did not help. Local application of
ointments and heat from an infrared lamp did not
help either.
The X-ray showed osteoarthritis. Manipulative
treatment of the left knee was done followed by
strapping and the quadriceps exercise. She
started feeling better after the third visit. By
the end of seven weeks she got rid of her
symptoms.
[index]
|
