Why does my knee keep ‘giving way’ ?
As a Consultant Orthopaedic and Knee Surgeon I have treated a number of patients with difficult knee conditions. A common complaint that affects many of my patients is the feeling of the ‘knee giving way’ which can often occur unexpectedly and cause instability and pain. Each of the following patients presented me with a history of an unstable knee, but the underlying problem in each is different.
Case Study 1: A sports injury
A 25 year old Ski Instructor attended my Knee Clinic and explained how on numerous occasions she had fallen in the snow whilst skiing. The bindings on her skis had not come off and as a result she felt immediate pain in her knee. She started to then experience her knee giving way from time to time especially on a twisting movement.
The Ski Instructor had sustained a cruciate ligament rupture (ACL). The Anterior Cruciate Ligament (ACL) is a key primary stabiliser of the knee joint. It prevents the knee giving way when the leg rotates outwards during pivoting and sporting movements. Injuries to the anterior cruciate ligament can occur during various sporting activities and in particular in sports such as skiing, football and rugby. This injury is sometimes associated with tears within the cartilage of the knee, and other ligament injuries such as the medial collateral ligament. Patients who have injured their anterior cruciate ligament tend to have a knee that gives way from time to time especially on sporting activity that involves turning and twisting. In time they can damage their knee irretrievably.
Over the last 20 years there have been tremendous advances in the treatment of various conditions of the knee via keyhole surgery. An ACL reconstruction is a very successful procedure if done well and a number of high level professional athletes return to their pre-injury sporting level after a careful reconstruction and good rehabilitation with physiotherapy.
Case Study 2: A work related injury
A 45 year old Carpenter came to see me after hurting his knee whilst working on a building site. It was initially painful but the pain appeared to have improved. It did however catch him from time to time and caused ‘niggling’ pain which caused him discomfort and instability.
The Carpenter had sustained a meniscal cartilage tear in his knee. The medial and lateral menisci are shock absorber cartilages inside the knee. It is a fairly elastic structure in the younger patient, but as the years go on becomes more fibrous. Therefore, they are often torn in sporting injuries and accidents in the younger patient, but can occur after minor twisting injuries as the patient approaches middle age. If diagnosed early, some meniscal tears can be repaired so that shock absorption inside the knee is maintained. Often they are diagnosed late and therefore the torn meniscus has to be removed via keyhole surgery. This is a highly successful procedure.
Cast Study 3: An Osteoarthritic knee
A 75 year old lady had developed a knock kneed deformity in her right leg and found that she could no longer trust her knee as it would occasionally give way, especially when she climbed down the stairs.
This lady has one type of osteoarthritis of the knee, which is the gradual wearing of surface cartilage which happens over the years. This can affect one part of the knee or large areas. Depending on the area that is worn, different patterns of pain and instability can be experienced by the patient. Generally early osteoarthritis can be managed with various conservative measures and it is very important to maintain a full range of motion in the joint with regular exercises. Conservative measures include regular exercises and physiotherapy, injections of cartilage protein, steroid injections and weight loss. When permanent pain and instability is a feature, partial or full joint replacement surgery may be indicated. Knee replacements are now extremely successful procedures with very high patient satisfaction rates. Knee replacements have advanced tremendously in the last 20 years and most patients now have rapid recovery programs enabling them to return home 2 or 3 days after surgery. Implants that are well fixed can last 15 – 20 years and return people to excellent function and give them pain relief and confidence in their knee.
Mr Sam Rajaratnam FRCS (Tr&Orth) is a Consultant Orthopaedic Surgeon specialising in knee and lower limb surgery at The Horder Centre in Crowborough.
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