Pain in The Knee Knee problems account for at least a third of the cases I see in my sport medicine practice. Many of these result from injuries in soccer, hockey or skiing, while the rest are due to gradual wear and tear. To better understand the knee, it’s helpful look at the anatomy. In the knee, the femur (thigh bone) has 2 large knuckles that rest on a plateau at the top of the tibia (shin bone). The bones are held together by ligaments, which are tough fibrous bands that allow bending and straightening of the leg (flexion and extension) with very little side-to-side motion. These ligaments can be torn if the knee is over-stressed. The bony surfaces are supported and protected by two types of cartilage: one is called meniscal and the other articular. There are two meniscal cartilages in each knee. They are rubbery bowl-shaped structures, which act like bumper pads for the knuckles of the femur. Twisting or rotational types of injury can easily tear these cartilages. Years ago, the treatment for this was to open up the knee and totally remove the torn cartilage, leaving the knee vulnerable to more rapid wear. Now tears can be more simply cleaned up by inserting a fibreoptic scope and instruments through tiny incisions in the skin. This process is called arthroscopy and has dramatically improved outcomes in many types of joint injury. Articular cartilage on the other hand is a tough, smooth protective layer covering the bony surfaces in the knee. It is kind of like linoleum over the “sub-floor” of bone. Excess wear can create holes in the cartilage thus exposing the underlying bone. The resulting bone-on-bone friction causes inflammation, which in turn leads to pain, stiffness and often swelling. This condition is known as osteoarthritis (OA). Sooner or later, all of us will have OA in one or another of our joints. The symptoms of OA in the knee can be relieved in many ways. First of all remaining active is very important to maintain function. It may be wise to shift away from activities such as jogging and move to walking, biking and swimming. Keeping the thigh and hamstring muscles strong and flexible also helps to maintain function. To learn how to do this properly, I advise seeing a physiotherapist. Many medications are available to help relieve symptoms. Tylenol is an effective and safe pain reliever. There is a whole family of oral anti-inflammatory medications (e.g. Advil, Motrin, Celebrex), which work well but may have more side effects. There are also some new topical versions, which are applied to the skin. Natural substances such as glucosamine have also been shown to be beneficial. For knees that don’t respond to the above, cortisone injections can be very effective. Cortisone is a potent anti-inflammatory that can be put right into the sore joint. Contrary to all the negatives people hear about cortisone, it is a very safe and relatively painless option. A second form of injection therapy involves improving the lubrication in the knee by injecting a substance called hyaluronic acid. This requires a series of 3 shots given a week apart. Another useful adjunct is a special type of support called an un-loader brace. These braces, which are usually custom made, help relieve pain by taking stress off the worn areas in the knee. Finally for troublesome knee symptoms that don’t respond to the above, the next step is knee replacement. This involves removing the worn out, painful bone and resurfacing it with plastic and metal. A new and less invasive procedure is available if there is wear on only one side of the knee.