The joints most kneedy
years of wearing a heavy backpack into remote areas, slipping and sliding
on steep terrain in search of wonder and solitude, attempting to find
another pristine high mountain lakeside campsite, I've noticed, more and
more, my knees ache at the end of the day--and, sometimes, before the
day has ended. Diagnosis: Worn out parts. Cause: Abuse and overuse. Cure:
Well . . .
I have become another of the numberless victims of the human body's joint
most vulnerable to wear and tear. No other of the skeletal system's 187
bone-to-bone connections causes as many chronic problems.
To take care of a knee, it is, perhaps, best to start with an understanding
of its construction and function. If your car fails to run properly, you
need some basic auto mechanics in order to decide 1) is it OK to keep
driving it? 2) are there things I can do to make it work better? and 3)
does it need a car doctor? Same goes for the human "machine."
Knees are directly comprised of three bones: the femur (thigh), the tibia
(which we touch when we say "shin"), and the patella (kneecap). Another
bone, the fibula, attaches behind the tibia, near the knee, but has no
specific influence on the joint.
Femurs and tibias articulate, or move against each other, when legs are
in motion. The articulating surfaces of the femur and tibia are semi-flat
and, to ensure a secure fit, each knee is padded with two C-shaped pieces
of cartilage, one on the outer half of joint space, the other on the inner
half. Called the medial (inside) meniscus and the lateral (outside) meniscus,
they also absorb some of the shock of movement. Placed strategically in
the knee, for additional padding, are fluid-filled sacks, called bursae,
at points of the greatest friction.
The knee is held together by ligaments--four of them. They're attached
at the points of highest stress. Connecting the femur to the tibia are
the medial and lateral collateral ligaments, on the inside and outside
of the knee. They provide stability for side-to-side motion. For back-to-front
and front-to-back stability, there are the cruciate (crossed) ligaments.
They run through the joint space, between the two menisci. Both cruciate
ligaments attach on their upper end to the femur, and on their lower end
to the tibia, and they're named for where they attach to the tibia. The
anterior (front) cruciate ligament (ACL)
attaches to the femur at the back of the knee and to the tibia in front,
thus preventing the knee from sliding too far forward. The posterior (rear)
cruciate ligament (PCL) attaches to the femur at the front of the knee
and the tibia at the rear, thus preventing the knee from sliding too far
backwards. Ligaments are made of connective tissue in which there is very,
very little elasticity.
When in motion, the great muscles of the leg provide additional support
to the knee. The quadriceps (thigh) muscles are a group of four muscles.
They taper down into one tendon that crosses the knee and attaches to
the top of the tibia. The patella lives in the middle of this tendon.
Three muscles in the back of the leg, the hamstrings, also help support
the knee. One attaches to the outside of the knee and the other two to
the inside. The calf muscle (gastrocnemius) attaches in two places to
the back of the femur and, finally, a long thin muscle runs from the groin
to the inside of the knee adding a touch more of support.
In addition, a long tough tendon, called the ilio-tibial band, runs from
your gluteals (the muscles of your hindquarters) down the thigh, across
the knee, attaching to the outside of the tibia. This band, too, gives
a bit of support.
You'd think, with all that support, the knee would last longer. Unfortunately,
the fittings are only moderately snug, the demands put on the joint are
great, and it is highly susceptible to damage.
From a trauma point of view, any force applied to the knee can partially
or totally severe a ligament (a sprain), a nasty injury. If the force
is applied to the outside of the knee, the medial collateral ligament
and anterior cruciate ligament may be involved, as well as the medial
cartilage. If the force is applied to the inside of the knee, the lateral
collateral could be torn and lateral cartilage may be ruptured. Twisting
forces may significantly damage the cruciate ligaments.
But the most common source of chronic knee pain is not injury but overuse
of the muscles that support the knee. When the muscles are stressed too
much, they tear (a strain) and create a great deal of discomfort. They
most often strain near their attachment to the knee. Tendonitis, an inflammation
of the tendons, has the same mechanism of injury. Muscle strains and tendonitis
are commonly mistaken by the patient as a torn ligament or cartilage.
This mistake is very common when the ilio-tibial band is involved. Since
the band is required for uphill motion, it is often abused when hikers
are unused to going uphill, or increase their uphill activity, especially
if they're wearing a pack. The problem, called ilio-tibial band syndrome,
causes pain primarily where the band attaches to the outside of the knee,
simulating a torn collateral ligament.
General knee pain may have other causes including patellar compression
syndrome, a problem created by too much pressure on the back of the kneecap
by too much walking, especially downhill. A dull ache, constant and nagging,
is the common complaint. Or, perhaps, the kneecap doesn't run quite correctly
in its track. The additional side-to-side motion of the kneecap puts additional
stress on its inner surface which eventually causes pain for up to several
hours after use. If the pain becomes chronic, never going away, the condition
may be chondromalacia of the patella. Chondromalacia refers to a disintegration
of the cartilage under the kneecap, probably caused by a chemical change
stimulated by past injury or overuse. The cartilage becomes frayed and
eroded. Interestingly, the cartilage can't hurt since it has no nerve
endings. So the pain must come from inflamed tissue around the cartilage.
ASSESSING THE DAMAGE
1. First, you need to assess the extent of the damage. Did the pain start
as the result of trauma (a forceful blow or twist) or overuse? If it was
trauma, was there a direct blow to the knee? Which way was the knee forced
to move? Did it twist? Was the foot planted when the force struck? Did
the hurt hiker hear any sounds, such as a popping noise? If it was overuse,
has the sufferer ever had this kind of knee pain before? Does it hurt
all the time or just when he or she moves? In both cases it is beneficial
to ask, Have you ever had pain like this before? If the pain came on suddenly
from trauma, especially if it made funny noises, and if it hurts most
of the time, the patient needs to see a doctor.
2. Visually inspect the damage. Take a look at the knees. Do both knees
look the same? Damaged knees may show swelling, discoloration, or some
other obvious deformity such as a kneecap in the wrong place. The more
a knee swells, and the more discolored it is, and the funnier it looks,
the more it needs a doctor.
3. Palpate the damage. Touch the hurt knee with your fingers, probing
gently. Do you find specific points of pain? Are the painful places over
ligaments or tendons? Does it hurt when you push down on the kneecap,
or wiggle it side-to-side? Is there pain along the line where the tibia
and femur meet? The more specific pain in the knee is, the more likely
there has been damage that needs repair.
4. Check range of motion of the knee. Can the patient flex and extend
the knee through its full range of motion? Or does it lock up or get too
painful to move past a certain point? Knees with a loss of range of motion
should be taken to a doctor.
5. Check laxity of the knee. Each of the four ligaments holding the tibia
to the femur can be individually assessed. These tests should be done
with the patient sitting down and the leg relaxed. If the patient is unable
to tolerate these checks, the knee needs a doctor.
The medial collateral ligament, the one on the inside of the leg, can
be checked by holding the ankle, with the knee slightly bent, and pushing
from the outside of the knee in. If it's loose or painful, stop pushing.
The lateral collateral ligament, on the outside of the leg, can be checked
in the exact opposite way, pushing from the inside of the knee out. Again,
looseness or pain is a sign to stop pushing.
The anterior cruciate ligament, one of two "crossed" ligaments inside
the knee joint, can be checked by bending the knee slightly and pulling
out on the tibia while pushing back on the femur. Watch for pain and looseness.
Posterior cruciate damage, which happens in only about one percent of
all knee injuries, can be checked simply by lifting the relaxed leg by
the ankle and letting the knee sag.
6. Test for function. This simple test should not be done until at least
one hour after pain starts. If the patient can stand and walk, do halfway
deep knee bends, and jump up and down on each knee individually, it's
fine to keep hiking on those knees.
REPAIRING THE DAMAGE
If the knee has been traumatized to the point where it can't be used,
the leg should be splinted, with the knee slightly flexed, and the patient
should be carried to a doctor for repairs. If the knee can be used carefully,
you can build a walking splint, one that wraps securely around the joint
but does not let the knee move, and the patient can hike out to a doctor.
Walking splints, like fixation splints, should hold the knee in a slightly
flexed position. You can build one by rolling a sleeping pad up from both
ends until you have something resembling two "jelly rolls." Wrapped around
the knee from the rear, the kneecap is left free of pressure. A soft but
firm pad (maybe a rolled up T-shirt) behind the knee keeps it slightly
flexed. Tied securely in place, the splint stabilizes the knee while allowing
walking. A stick or ski pole for a "walking stick" adds to the patient's
stability. If you have an inflatable sleeping pad, such as a ThermaRest,
you can deflate it, build the splint, secure it in place, then inflate
the pad for even greater support. Crazy Creek Chairs also make great walking
If your knee hurts from overuse, you might be able to ease the pain by
strenghtening the muscles surrounding the knee. with access to a weight
machine, you would do well to regularly--say, three times a week--perform
sets of hamstring curls and knee extensions. leg presses also strengthen
the knee area. don't use more weight than you can easily control, and
do the exercises slow and precise instead of flinging the weight up and
down. keep your feet and ankles turned slightly outward during the exercises
to emphasize the inner thigh muscles. the vastus medialis--on the inside
of your knee--is often weak in backpackers compared to the vastus lateralis,
and this weakness pulls the knee out of line, a source of pain. without
a weight machine, you can do lunges and "wall sits." a wall sit is like
a supported squat. press your back against a wall and slowly sit down
until your legs are flexed at about 130 degrees. don't go all the way
down to 90 degrees. at 130 degrees the vastus medialis gets a good workout.
during these exercises, keep your lower leg perpendicular to the platform
of your foot to better strengthen the knee. if you don't get better, see
a doc for an evaulation. sometimes knee pain is related to foot structure,
and an orthotic could help. sometimes a knee brace can be the thing you
RICE speeds the healing and eases the discomfort of all levels of knee
pain. Apply RICE several times a day until the pain is gone. RICE is Rest,
Ice, Compression, and Elevation. Rest means get off the joint. Ice means
cool the joint with ice, snow, chemical cold packs, or cold water. (Note:
ice, snow, or cold packs should not be put directly on naked skin. A bandanna
will provide enough insulation between the cold and the skin.) Compression
means wrap the knee in an elastic wrap, but not too tight. Elevation means
keep the knee higher than the patient's heart. RICE should be applied
for 20-30 minutes, then taken off. RICE-ing three or four times each day
should be enough. In addition, over-the-counter anti-inflammatory drugs
(aspirin, ibuprofen) ease pain and speed healing. These drugs should be
taken with food and plenty of water. The dose of an anti-inflammatory
drug you take might be upped beyond what is recommended on the bottle,
but you need a physician's advice about how much to increase the dose.
Overuse injuries can be assessed the same as traumatic injuries. If an
overuse injury is bad enough to splint, it should be taken to a doctor,
along with the rest of the patient. RICE and anti-inflammatory drugs will,
once again, ease pain and speed healing. Gentle massage and mild stretching
exercises often make the knee feel better and mend quicker.
It's nice to know exactly what's going on, but in all instances, your
job is not to figure out exactly what's wrong with a painful knee. Your
job is to figure out how to deal with the pain and whether or not the
pain should be evaluated by a physician.