MAMCOTS | Knee Joint Clinical Orthopaedics & Examination | Dr. P. S. Mamtora

Histopathological assessment of degenerative articular cartilage will reveal a gradually accelerating congregation of chondrocytes and fibrillation, with impaired formation of proteoglycans, resulting in poor maintenance of mechanical resilience and further erosions. The pathophysiology worsens as one ages and can be seen as - Asymmetric cartilage loss - Fibrillation of the articular surface, reduced/abnormal load sharing leading to microfractures, Subchondral sclerosis - Bone repair Subchondral cyst formation and Marginal osteophytes - New bone formation. Abnormal stress and altered biomechanics trigger an inflammatory response, resulting in effusion and synovitis experienced as pain, stiffness and swelling.

The degenerative changes in a cartilage comprise of impaired ability of chondrocytes to produce proteoglycans and collagen matrix which reduces the shock absorbing capacity, imparting excess load to the subchondral bone, leading to microfracture which heals by sclerosis and oedema. Osteophytes are formed as a result of new bone formation. The symptoms of OA are due resultant inflammatory reaction as cartilage is avascular. The cartilage receives nutrition from synovium via diffusion as a result of loading and unloading, hence exercises play a prime role and prolonged sitting in one position should be avoided.

The Degenerative mechanism often begins in the third decade of life as microscopic histochemical changes in all tissues of the body. This degeneration, though inevitable, can have its symptoms reduced by regular exercise, endurance activities and stretching.

Palpation includes tenderness over the joint line and at the muscle and ligament attachment sites. Evaluate knee joint range of motion from 0 to 140. Look for cruciate ligament laxity (anterior and posterior drawer tests) and for medial collateral and lateral collateral ligament laxity (valgus and varus stress tests). Pain during resisted active movement points to pathology in that particular muscle. Feel the IT band for any tightness, which is common in runners.

When examining the knee in osteoarthritis, it is crucial to determine whether the pain arises from intra-articular or periarticular sources. Pain when getting up from a chair or going down stairs, other than patellofemoral involvement, may indicate hamstring medial tendinopathy; examine for tenderness over the medial hamstring tendon/its attachment, and confirm by stretching the hamstrings.

Idiopathic in origin, seen often in young females, presenting as anterior knee pain with a positive cinema sign is classic for chondromalacia patella. Getting up from a sitting position could also be due to hamstring tendinitis, in addition to patellofemoral pathology. Focal degeneration seen as thinned cartilage on MRI, patellar tilt, and patellar maltracking can also cause chondromalacia patella due to a weak vastus medialis.

The claim that pes planus causes knee osteoarthritis has been refuted by long-term studies. Studies on some tribes with completely flat feet demonstrated no evidence of knee or foot pain.

As the medial articular cartilage wears out, the MCL (Medial Collateral Ligament) becomes lax; hence, on Valgus stress, medial laxity is demonstrated, which is NOT due to a ligament tear but due to a reduction in the size of the articular cartilage.

Knee locking has an acute onset with inability to move the knee in either direction, associated with pain, and often, once the cause (meniscal tear or loose body) is addressed, it resolves. Flexion deformity is chronic, with inability to extend the knee beyond a point. Another probable pathology which blocks with pain and art from synovitis and effusion is degenerative posterior horn meniscal oedema and myxoid oedema of the ACL, which can be detected on MRI.

Popliteal cysts: synovial outpouchings often seen on the posteromedial aspect of the knee, occasionally in the popliteal fossa, and rarely on the posterolateral aspect. Pain arising from a popliteal cyst is often due to inflammation. A ruptured Baker's cyst, often a part of OA knee presenting as sudden, severe pain, can mimic acute DVT with common features of severe calf tenderness, generalised swelling, with occasional pitting oedema. Imperative, then, is to rule out DVT with sonography (to detect cysts and fluid in the calf muscles), venous colour Doppler, and D-dimer.

Knee pain can be due to a tight gastrocnemius from inadequate stretching, with tenderness at the gastrocnemius attachment — either the medial or lateral head. Resisted calf action (plantar flexion) causes pain at the popliteal gastrocnemius due to gastrocnemius attachment tendinopathy. A very poor muscle mid-substance to mid-substance tear of the calf muscle with strenuous activity like running, presenting with ecchymosis and tenderness. Tight gastrocnemius may result in tendinopathy at the Achilles attachment, and, due to the altered windlass effect, there may be resultant inflammation at the plantar fascia attachment—heel pain. The heel pain often responds to myofascial release of the tight gastrocnemius.

Kinetic chain dysfunction - Impaired functioning of short rotators of hip and gluteus Medius combined with weak vastus medialis leads to impaired locking of knee to compensate this internal rotation of knee is attempted and tensor fascia lata has to overwork and consequentially the IT band gets tight. Correction of kinetic chain with appropriate physiotherapy relieves the symptoms.

A meticulously taken history of the patient shall lead to a well-planned and focused clinical examination, which shall not only establish a provisional diagnosis but also form a rationale for further management - both medical and physical therapy.

A complete history taking is the one with meticulous well intended questions with proper logical analysis of the answers and confirming the same on clinical examination. The case explores that the knee pain can have an origin in the spine and correction of the kinetic chain by appropriate physiotherapy leads to faster recovery.

Repetitive rotational stress involved with trekking may instigate early OA knees first denoted by cartilage and meniscal wear and tear at the microscopic level when left unattended may predispose to degenerative tears of the meniscus, injury to meniscal roots accelerate stress on the articular cartilage, progressing to articular degeneration and invariably osteoarthritis. Similar mechanism occurs in football and basketball players and only way out is to religiously perform proprioception exercise and stretches.

Outdoor walking or running on any surface has a greater advantage over walking on a treadmill; as in the latter the speed of the treadmill regulates the person's walking or running speed and in the former the person decides for himself the speed and can alter as per his comfort, thus reduces stress on the knees and the back.

Different Radiological presentations of OA knees - the early changes of OA picked up on X ray are medial space reduction, tibial spiking, early osteophytes, thin sub chondral sclerosis to florid picture of significant subchondral sclerosis, large osteophytes that permanently restrict flexion and complete obliteration of joint space. Always ask for X ray knee in AP standing -weight bearing. Sky line view for better patellar viewing.

Among the other changes such as osteophytes, anterior subluxation, effusion, MRI may reveal subchondral marrow oedema which may clinically present as acute, sudden pain without any gross synovitis or effusion, due to either a stress fracture or SPONC (Spontaneous Osteo Necrosis of the articular Cartilage). Often rest will settle the acute pain due to the oedema. Cartigram - Cartilage mapping in OA knee or suspecting a chondromalacia patella demonstrates the quality of the cartilage.

Clinical exeprience suggests that often in painful refractory OA knee there could be underlying hypothyroidism which needs to be tested and the often the pain responds to management of hypothyroidism. Weight reduction, knee exercises - stretches and strengthening, changing position every 15-20 minutes if sitting in cross legged position on floor.

Based on the pathoanatomy determined post history and examination, the selection of homoeopathic remedies becomes simpler and more scientific. A word of caution - The drugs suggested below are specific, based on an array of vast clinical experience of Dr Mamtora Sir in Homoeopathic OPDs and his interactions with various Homoeopaths.

Apart from diagnosis, the age of the patient at onset of OA, determines the posology and the miasm. A word of caution - The drugs suggested below are specifics based over array of vast clinical exeprience of Dr. Mamtora Sir in Homoeopathic OPDs and his interactions with various Homoeopaths.

In acute symptomatic knee OA, a physiotherapist may guide with suitable physical therapy. Long-term maintenance should follow a regular exercise regimen. The dictum is - Tight muscles require stretching and weak muscles require strengthening, Myofascial release of tight areas, eccentric loading if there is tendinopathy. Other auxiliary modes, as per the case, may be: brace (tubular, off - loader brace) and thermal modality (heat/cold).

The conservative OA knee management comprises of medicines, lifestyle changes and auxiliary modes. The modality chosen needs to be in alignment with each patient's knee pathology and life style.

TKR is usually advised based on the patient's symptoms rather than a comprehensive knee OA protocol, which comprises customised therapy protocols, weight reduction, a long-term exercise program, and analgesics and NSAIDs when symptomatic.

Repetitive rotational stress from trekking may instigate early OA in the knees, first evidenced by cartilage and meniscal wear and tear at the microscopic level; when left unattended, it may predispose to degenerative tears of the meniscus. Injury to meniscal roots accelerates stress on the articular cartilage, progressing to articular degeneration and, invariably, osteoarthritis. A similar mechanism occurs in football and basketball players, and the only way out is to religiously perform proprioception exercises and stretches.

Outdoor walking or running on any surface has a greater advantage over walking on a treadmill; as in the latter the speed of the treadmill regulates the person's walking or running speed and in the former the person decides for himself the speed and can alter as per his comfort, thus reduces stress on the knees and the back.