By James N. Dillard, M.D.
(04/16/2009) The knee is a great joint, if you are walking on all fours. If you’re standing upright on two legs, it’s not such a great
 Abbey Allen
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design, particularly if a 300-pound tackle smashes into it.
You don’t need to be a professional athlete to have knee trouble, but it does seem to help. Football and hockey players have the most knee problems, though even the golfer Tiger Woods just had knee surgery last year. If you have a bad knee or two, you are among 13.5 million Americans who have knee arthritis or 19 million who saw a doctor for knee pain last year.
New knee pain comes most often from twisting or turning the wrong way, overuse, poor athletic form, or an acute injury. Long-lasting knee pain comes from arthritis, an old injury, inflexibility, or inflammation of a tendon, bursa, or joint lining. Extra weight will always make these problems significantly worse.
Only very rarely is knee pain caused by serious medical illness like infection, tumor, or a hidden fracture. But you should always see your doctor if you have new deformity, locking, clicking, buckling, swelling, or redness and warmth in a knee, or if new knee pain persists after three to four days of home treatment (ice, heat) and rest. In this area, new knee pain might be a sign of Lyme disease.
Most people know these things, but here are some things that most people, and even a lot of doctors, don’t know.
Don’t be so impressed by magnetic resonamce scans — they don’t show where the pain is. People think that because they are so fancy and high-tech they will just make the diagnosis for you. This is not true. M.R.I.s are often way overinterpreted. And plenty of people with very abnormal M.R.I.s have no pain or disability at all. I’ve had a torn cartilage in my left knee for 20 years with no pain, and I tolerate several high-impact sports pretty well.
If you don’t believe me, then you need to read a critically important article on the mismatch between M.R.I.s and pain by Gina Kolata in the Dec. 8, 2008, edition of The New York Times. It is called “The Evidence Gap,” and your friendly local reference librarian can help you obtain a copy.
This is essential reading for anyone suffering from orthopedic or spine pain who may be considering surgery. And any doctor who does not understand these concepts may not help you make the best decisions for your care.
Don’t be in a huge hurry to get knee arthroscopy. In a landmark study published in the July 11, 2002, issue of The New England Journal of Medicine, researchers at Baylor University in Houston did real knee arthroscopies in half of 165 subjects and did a fake surgery in the other half. They even put nicks in the skin around the knee for the sham group.
The outcomes for the two groups, real versus fake surgery, were exactly the same.
In fairness to my surgical colleagues, I have to say that knee replacement surgery is one of the most successful procedures that I see. If your knee is truly worn out, and we’ve done all the injections and rehab and pain management that we reasonably can do, then I’ll be pushing you to get the joint replaced.
That’s because I know you’ll be much happier a few months from now, after the postoperative rehab is done and you’re climbing stairs without pain.
For most of you, don’t bother with knee braces. The most you’ll ever need is a soft, neoprene sleeve, maybe with some side stays and hinges. Closets across America contain expensive, custom-built knee braces that are gathering dust. They don’t work very well, don’t help much, and generally are not worth the money spent.
If you have a bum knee, then you’ve probably had physical therapy. But there’s good P.T., and not-so-good P.T. If it’s done really well, therapy can often make you all better. But for many with knee pain or arthritis, you have to become your own physical therapist. You will need to do stretches and exercises at home or in the gym on a regular basis to keep the knee from hurting and getting worse.
Two key stretches involve the hamstrings and the quadriceps muscles. If you sit on the floor with your legs out straight, you should be able to touch your toes. If you only get to your shins or ankles, then your hamstring muscles are too tight.
If you are lying on your stomach on the bed, you should be able to bring your heel within an inch or two of your butt. If you can’t do this, then your quadriceps muscles are too tight. These tight muscles can make your knees worse. Your physical therapist or athletic trainer can show you how to stretch them out, bit by bit, at home.
Acupuncture has some very positive research results for knee pain, much better than arthroscopy. If you have knee arthritis, you need to be on the anti-inflammatory diet (see my online archive “Too Hot to Handle” at easthamptonstar.com and try three months of glucosamine and chondroitin supplementation. It does help some people, and may preserve cartilage.
If you pronate (roll your ankle inward) as you walk or run, this puts strain on your knee with every step. A good podiatrist, orthopedist, or rehab doc can help you with this. There’s usually not one single magic-bullet answer for bad knees. It takes proper rehab, regular self-care, weight loss, stretching and strengthening, some good medical care, and a dash of the complementary therapies to keep your bum knee serving your needs for as long as possible.
Dr. James Dillard practices orthopedic rehabilitation, pain management, and complementary medicine in Wainscott, East Hampton, and in New York City. Questions can be directed to jdillard@ehstar.com.