April 10, 2003

Note to our users: This interactive feature is in no way a substitute for the examination and advice of a physician. You are responsible for all actions you take after reading material on this site. Always seek the advice of a doctor for concerns about your health or a specific condition.

Knee1: Dr. Sklar is a partner at New England Orthopedic Surgeons, where he specializes in sports medicine and knee arthroscopy.

Knee1: He graduated from the University of Pennsylvania, where he obtained his undergraduate degree in psychology before graduating from U of Penn's School of Medicine.

Knee1: He is a member of the American Board of Orthopedic Surgery, the American Academy of Orthopedic Surgeons, the Arthroscopic Association of North America, the American College of Sports Medicine, and sits on the Board of Directors for the Massachusetts Orthopedic Association.

Knee1: Dr. Sklar, why don't we begin by having you tell us how you began your career in orthopedics?

Dr. Sklar: I wanted to be a surgeon and I was very attracted to the mechanical aspects of orthopedic surgery. I took extra rotations in medical school and then gained admission to the Harvard Combined Orthopedic Residency.

Knee1: Great! Users, we welcome your questions.

CONNIE OSBORNE: My 86 year old mother has severe osteoarthritis in both knees. She needs both knees replaced, but she is not a candidate for such an intensive operation. Is there anything that you could suggest that could give her some relief from the pain? Of course, we have tried every shot and rub that we hear of. Thank you for your assistance. We would certainly appreciate any suggestions.

Dr. Sklar: Tough problem. Options include physical therapy done gently, which, for some reason, helps many patients with arthritis, injections of Hyalgan, braces.

michaelp: Dr. Sklar, for the past 3-4 years, I have experienced snapping sounds originating from the tendons/ligaments at the side of my knees. I have no other symptoms. I believe this may be due to an increase in the flexibility of these tendons/ligaments as caused by stretching exercises. Is there any way to decrease the annoying snapping sounds my joints are making, such as through specific exercises?

Dr. Sklar: Physical therapists can sometimes use deep friction massage to loosen the bands that are snapping. Other options are injections of cortisone or surgical release.

karen: how long does it usually take for a Fulkerson osteotomy to heal, and when do you think the other knee can be done? I have OA in both knees and had the procedure done on my right knee in January.

Dr. Sklar: The bone pieces usually heal in 8 weeks; strength and endurance take another 6 to 8 weeks. I let my patients decide any time after 8 or 10 weeks when they want the surgery on the other leg.

ruthierw: Is PCL reconstruction something you would recommend for a 16 year old boy that tore his PCL and is a track scholarship hopeful? If so, how soon after the injury should the surgery be done?

Dr. Sklar: The decision about whether to reconstruct a PCL tear depends on how loose the knee is. Slightly loose knees can be left alone - on the other hand, a very loose knee from a PCL tear should be reconstructed, especially given his age.

kathryn: I fractured my knee cap in high school (15 years ago)- a small part of knee cap was removed. I get pain along the outside portion of my kneecap where the piece was removed. Is there anything that can be done to relieve this pain?

Dr. Sklar: It depends on whether you have significant arthritis in the kneecap. Try physical therapy with a skilled knee therapist, anti-inflammatories, and see how it does. If this doesn't work, there are some surgical options, which can alleviate your pain.

Mark: Are you a fan of orthotics? I have had knee pain for the past 3 years - male/28/triathlete/155 lbs. Started from poor training. Eventually got orthotics 3 times - lead to IT problems. Finally had surgery on left knee - just a minor cleanup job. Bone scans, MRI's, x-rays were all normal. Did PT, etc. strengthening exercises, injections behind IT bands, protherapy. IT bands are better, but still have superficial knee pain. Any thoughts (yeah, this is tough since you can't see me)? I'm pretty much a neutral runner - not sure if problem is from biking or running. The alignment isn't bad - so say the PTs.

Dr. Sklar: Tough problem. Bikers and runners are very prone to inflammation around the lateral aspect of their kneecaps or of the IT band. It may be that your patella should be released or the IT band released if all else has failed. It is not surprising that nothing showed up on the studies since the conditions I speak of are not picked up by MRI or bone scan. A simple arthroscopy would also not be predicted to work.

karen: I am only 28 yrs old and am in pain with my left knee. Is there anything I can take for it? Currently on Tylenol Arthritis. No pain meds due to psychiatrist.

Dr. Sklar: The first thing you need is a proper diagnosis. You should see an orthopedic surgeon and be evaluated. In the meantime, if Tylenol is not working, and if you don't have any sensitivity to it, you might try Ibuprofen or Aleve. I can't emphasize enough how important it is to get a proper diagnosis from someone familiar with knee problems rather than just taking pain medicine.

JT: I play indoor sports on the new weave grass with the shredded rubber in it. I have noticed since switching to this surface I often get soreness and light bruising just below the kneecap on the outside of the leg. This is often accompanied by my ankle being sore from getting pinned while I move. Is this likely just a normal strain from the leg movement being interrupted? Or indicative of a potential knee problem? Thanks.

Dr. Sklar: The things you complain of are signs of inflammation. Either this surface lacks the give that your knees were used to before, or else you are doing more than you are used to. In either case, I don't consider the pain and swelling "normal strain". Pain is your body's protective mechanism or warning sign. Pay close attention to it. Cut back for now and have someone knowledgeable in sports medicine look you over.

jfrata041: I have a 14 year old daughter that has been complaining of knee pains. She says the pain is with in the knee and when ever she turns her knee in or out it hurts her. She doesn't recall hurting it but last weekend we were moving things and she said she sat indian style on the floor and tha's all when it happened. What could be wrong?

Dr. Sklar: There are two possibilities that come to mind. The most common is damage to the back of the kneecap or chondromalacia of the patella. Another possibility is a tear of one of the cartilages in her knee. Sounds like she needs to be evaluated.

almayor: I have gone thru 3 surgeries for my torn ligaments, ACL, PCL, MCL. My last surgery was last Dec. and every now and then Ii get a pain right on my shin. Is this normal? I have never experienced this pain from the previous surgeries. How long do you think is recovery from this....I still walk with a limp and my leg is still swollen...

Dr. Sklar: You had a very severe injury. A three-ligament knee rupture is one of the most traumatic events that a knee can endure. Shin pain after knee surgery could be related to hardware that was used to fix the ligaments. Another alternative is that you have developed some inflammation in the process of rehabilitation. It is not uncommon to limp four months after surgery for this problem, nor is swelling uncommon. I tell my patients that it can take six to eight months after such surgery before they start to feel close to normal. I would tell your surgeon about the shin pain and have him evaluate it.

david scott: I am 46 and have advanced osteoarthritis in my left knee. I have had arthroscopy twice but my surgeon says that all I can do now is manage the condition and wait for a knee replacement when I am 60. I understand that new technology is becoming available that allows knee replacements in younger people. What should I do?

Dr. Sklar: You are old enough to have a knee replacement if you have severe pain and cannot function. We believe that waiting until 60 is not appropriate anymore. Newer knee replacement designs are predicted to last 20 years or more if you don't over do it. Why suffer another 10 or 14 years during your prime?

karen: I have seen an orthopedic surgeon. Had Fulkerson osteotomy in January on right knee. Dr said Ibuprofen affects the healing process. I also have tried anti inflammatory (lodine) and cortisone shot in right knee. They didn't work so not trying it in left knee. DX: OA both knees. Waiting on right one to heal enough so I can have left one done. What do you recommend for the pain now that you have some history?

Knee1: Note to our users: "DX" means "diagnosis" and "OA" stands for "osteoarthritis"

Dr. Sklar: Ask your doctors about Darvocet. There are also pain patches that can be applied to the skin. Your osteotomy may be healed enough by now to allow you to take NSAIDs.

Bradley: Is there a surgery alternative for someone who just has worn out knees? I am only 21 and my knees are already starting to bother me, there is a little history in my family of knee problems. I am very careful of my knees now.

Dr. Sklar: Why do you think they are "worn out"?

Bradley: I get pain occasionally in my knees after some slight stress on them, and the weather also seems to affect them. I was a runner for: track = 4 years, CC=3 years, Soccer = 5 years, Marching band = 4 years. I went for x-rays and then a doctor, who has retired, prescribed Naproxin.

Bradley: I guess I am really looking for ways to circumvent further damage, possible by strengthening my legs?

Dr. Sklar: Sounds like your knees have been in excellent shape until recently. I would be surprised if a knee specialist or general orthopedist couldn't find some things like exercises, orthotics, good shoes, and maybe glucosamine to prescribe for you that would make you have less trouble and function at a higher level.

Tony: I had arthroscopy surgery for a lesion in the middle femur condyle with 6mm injury. They made a graft transfer (OATS) since the surgery I have pain in the patella area and still 13 weeks from surgery I cant go up the stairs with that knee (right) without a sharp pain. I never felt that before surgery is that common? Or normal at this time.

Dr. Sklar: Sometimes the graft is taken from under the patella. Sometimes, the knee becomes deconditioned. Sometimes the patella can be scarred over to one side from the surgery. All of these conditions can cause you pain with stairs or squatting and kneeling. It is still early after your surgery relatively speaking and I would inquire of your surgeon about what he thinks is the matter and what he proposes to do.

nicefields@hotmail.com: What exercises should, or should not, a person do if a microfracture has been done. I would like to continue to play beach volleyball if possible.

Dr. Sklar: Much depends on where the microfracture was done and on how great an area was treated, and whether it has successfully brought about cartilage healing. I would consult with the surgeon about what exercises he thinks are appropriate. Volleyball, because of all the jumping and landing, is notoriously tough on knees, as you probably know. If you were to go back to it, you would need a good deal of strengthening and conditioning beforehand.

teenie_boggs76: I had an ACL reconstruction last year in Jan. on my left knee, they took an autograft from my right knee. After the surgery I went home, where I did fine until the next morning when I went to the restroom. Apparently the patella tendon in my right knee tore causing me to fall, which in turn tore the muscles across my right knee and broke a piece of my kneecap. The doctor fixed it a few days later, but now I feel uneasy on my right knee sometimes. Is it because my knee still isn't strong? Sometimes it feels like it shifts, but the doctor checked it out and said there's nothing wrong with it. What do you think it is, just weak muscles?

Dr. Sklar: You had a severe double trauma to your right kneecap: first the graft harvest, and then the rupture and fracture when you fell. If your doctor has evaluated everything with x-rays and exam, and says it looks good, then you may just need some more time and good physical therapy. One thing you should know about patella tendon grafts - even those that don't lead to a rupture - is that 15% to 20% of patients have persistent discomfort where the graft was taken for years after the surgery.

Lynnie: I have had many knee surgeries, from lateral release to meniscus tears, clean-outs, for scar tissue, and I also had 2 Maquet procedures. The last one I wound up with a serious infection and had to have the screw taken out after 6 weeks. Was on a pic line for 8 weeks. I recently had a bone scan because of constant pain in my knee still, and both the bone scan and the tagged white cell count said I had active infection in the knee. Dr. did a bone biopsy, and the results of that said I didn't have any more infection. I am confused. My knee still hurts all the time, I am constantly taking pain med. and I am concerned on two points: 1) that I may still have infection deep in the joint, and 2) that my knee could be so damaged from the infection, plus all the surgeries that maybe its time for a new knee? What do you think?

Dr. Sklar: I share your two concerns. the biopsy may have missed the area in which the infection was located. Other tests that would help are MRI with contrast, a sed rate, and a CRP test. If there is no infection, in fact, it may be irritation at the site of the bone elevation, or persistent arthritis in the knee itself.

Knee1: We're just about out of time. Dr. Sklar, do you have any closing thoughts for our users?

Dr. Sklar: The knee is the most commonly injured joint in the body. It takes tremendous stress when we exercise. Slight imbalances can cause pain and dysfunction. If you have any history of knee problems, it is a good idea to be evaluated and to have an exercise prescription given. If you don't, always start gradually and build up slowly when you exercise or play sports.

Knee1: Dr. Sklar, thank you for your time and expertise. Users, thank you for joining us today. Stay tuned for upcoming Knee1 discussions!