THE JOINTS MOST KNEEDY
by Buck Tilton

After thirty-five 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 – 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? 3.) Does it need a car doctor? The same goes for the human "machine."

BODY MECHANICS
Knees are directly comprised of three bones: the femur (thigh), the tibia (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. The medial (inside) meniscus and the lateral (outside) meniscus also absorb some of the shock of movement. Placed strategically at points of the greatest friction in the knee, for additional padding, are fluid-filled sacks, called bursae.

The knee is held together by ligaments – four of them. These are 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. These 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 are 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 to 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 called 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. Finally, a long thin muscle runs from the groin to the inside of the knee, adding a touch more 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 sever 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.

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 traveling 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, 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.) 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 injured 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, the more discolored it is, and the funnier it looks, the more imperative it is to see 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 the 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, 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 the 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.

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, so 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 Therm-a-Rest®, 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 knee splints.

If your knee hurts from overuse, you might be able to ease the pain by strengthening 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 slowly and precisely 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, causing 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 doctor 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 need.

RICE (Rest, Ice, Compression, and Elevation) speeds the healing process and eases the discomfort of all levels of knee pain. Apply RICE several times a day until the pain is gone. 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 to speed the healing process. 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 way 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 the pain should be evaluated by a physician.