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KNEE PROBLEMS

If you're reading this article, you or someone you know probably has a knee problem. Maybe you've injured your knee while skiing or playing sports, or perhaps you're one of the millions of Americans who suffer from arthritis. You may have recently undergone knee surgery or are contemplating having surgery. Whatever the nature of your problem, you're not alone.

According to the American Academy of Orthopaedic Surgeons, some 4.2 million initial visits to doctors were made for knee problems in 1992 (the latest statistics available). That same year, another 1.3 million initial visits were made to emergency rooms because of knee injuries or knee pain. This is not surprising given the fact that nearly half of all people between 25 and 75 years old have experienced knee pain.

Many of them end up in my office. I am an orthopedic surgeon who specializes in the diagnosis and treatment of knee problems. At the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, affiliated with Beth Israel Medical Center in New York, I treat hundreds of patients each year for a wide variety of knee complaints. Knee problems don't discriminate. In my capacity as team doctor for the New York Knicks and former physician for the New York Rangers, my patients include some of the best-conditioned, finest athletes in the world. But I spend the majority of my time treating the so-called weekend athletes—people who sit at their desks all week long and, come Saturday or Sunday, play hard and sometimes get hurt. I also see a fair number of sedentary people who are not the slightest bit athletic and who have problem knees for different reasons.

Why are knee injuries so common? In order to answer this question, I need to explain a bit about the anatomy of the knee joint. By definition, a joint is a point in the body where two or more bones connect. In the case of the knee, however, the story is far more complex. The thigh bone (femur) connects to two bones: the shinbone (tibia), which lies directly underneath, and the fibula, a long bone on the outside of the leg. Another small bone, called the patella, or kneecap, sits on top between the two. Bones are connected to other bones by ligaments, thick fibrous bands of tissue. Muscles, which move the bones, are connected to them by tendons. The entire bone ends are lined in a smooth material called articular cartilage, which prevents the bones from rubbing against each other and allows them to glide smoothly.

You may think that the knee is merely a hinge that connects the upper leg to the lower leg, but it is far more than that. The knee is actually an exquisitely designed machine. With every step you take, your knee is providing both stability and mobility. Your knee is designed to allow for a full range of motion— it moves from front to back, side to side, and up and down. It enables you to walk on a level surface, run up stairs, pivot, twist, and turn. You can kick your leg forward or fling it backward. You can stand, dance, swim, ski, or bicycle, thanks to your knees.

Your knees work very hard. The average person takes between 12,000 and 15,000 steps per day. With each step, your knees sustain a force of anywhere between two and seven times your body weight, depending on what you're doing. If you spend your day walking on carpet, the forces exerted through the knee are lower than if you're walking on hard pavement. If you jog or run, walk up stairs, or use a stair machine, the forces exerted through your knee can exceed 2,000 pounds! Over time, if your knee is continually bombarded and overworked, it will begin to "complain."

I don't mean to suggest that knee injuries are inevitable— far from it. One of the reasons I am writing this book is to show how many knee injuries can be prevented, and a good portion of this book is devoted to prevention. A good muscle-strengthening program is the best defense against knee injuries, I show you exactly what you need to do to protect against knee injuries. In addition, many people inadvertently do things that put their knees in jeopardy. Throughout this article, I offer advice on how to avoid activities that are true "knee killers." This article is also designed to help people whose knees are already "killing" them and are in the midst of considering their treatment options.

I am also writing this article because I feel that today, more than at any other time in our modern history, patients need to be fully informed. The cost-cutting environment in which medicine is being practiced is, in my opinion, detrimental to patient care. Physicians are often rushed and burdened with paperwork. Many insurance companies are so zealous to cut costs that they are actually discouraging patients from seeking appropriate care and refuse to pay for it when they do. Many patients in health maintenance organizations are finding it increasingly difficult to see a specialist of any kind, and knee surgeons are no exception.

As good as a general practitioner or internist may be, he or she cannot have the breadth of knowledge required to treat knee problems. The typical generalist has had at most a three-week rotation in all of orthopedic medicine as part of his or her medical training. The practice of orthopedics today, however, is highly technical and highly specialized. A physician who is not performing knee surgery and who is not up on the current literature is not going to be adept at making a diagnosis or designing a treatment plan. More and more, it is incumbent upon patients to arm themselves with the right information so that they can advocate for themselves. If present trends continue, only the most-educated, aggressive patients will be able to navigate through the health care system and get the care they need.

In recent years, there have been spectacular changes in the practice of orthopedic medicine that have revolutionized the diagnosis and treatment of knee problems. Knee surgery no longer means weeks or months of immobilization and a lengthy recovery period. More and more, surgery is being performed on an outpatient basis, and most people can walk out of the hospital with nothing more than an Ace bandage on their knee. A procedure called arthroscopy makes it possible for surgeons to perform intricate surgery through an incision about the size of a buttonhole. In many cases, a patient may come in for surgery in the morning, be up and around by afternoon, and go back to work the next day. A remarkable prosthesis—the total knee replacement—enables people who were once crippled with arthritis to enjoy pain-free mobility. Today, hundreds of thousands of Americans have total knee replacements, and many are not only walking, but are playing doubles tennis and even engaging in other sports.

In addition, there have been advancements made in the nonsurgical treatment of knee problems that are equally impressive, notably in the field of exercise rehabilitation. Under the direction of Robert Gotlin, D.O., the rehabilitation center at the Beth Israel Hospital, North Division, has made enormous strides in the treatment of knee problems. With the right exercise program, knee patients are able to regain motion and strength faster than ever before. With Dr. Gotlin's help, I have included several rehabilitation programs for common knee problems in this book.

I have found that very often patients worry needlessly about the wrong things and ignore the really important ones. For example, patients are often very preoccupied with knee noise; they think that every creaking and cracking sound is an indication of a serious problem. It is not—noise without pain and swelling is not significant. But I can't tell you how many patients are certain that they have a "bum knee" because they hear these sounds. Pain is another symptom that is often misunderstood. People usually assume that pain is a sign of a serious problem. Paradoxically, when it comes to the knee, there is often no correlation between pain and degree of injury. A relatively healthy knee can hurt constantly, and yet a seriously "sick" knee may cause very little discomfort. Although this concept is difficult for patients to grasp (especially if they are the ones feeling the pain), once they become acquainted with the unique anatomy of the knee, which I explain in the next chapter, they will understand why pain is not the best way to diagnose a knee problem. They will also learn how to better manage their pain and, hopefully, reduce their discomfort to a minimum.

This book is not intended to replace your physician. Rather, the goal of this book is to help you work better with your physician. A knowledgeable patient will ask the right questions and will have realistic expectations about what to expect from each potential treatment. In the end, a well-informed patient will be able to make the right treatment choices and will be better prepared to work with his or her physician in a constructive way.

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