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About Jonathan Franklin

Jonathan Franklin, MD (Retired) Dr. Franklin is a board-certified orthopedic surgeon with a clinical focus in arthroscopic and reconstructive knee surgery, arthroscopic shoulder surgery, as well as knee replacement surgery. Dr. Franklin has a strong background in sports medicine, and treats many high school, as well as recreational and professional athletes for a wide variety of sports injuries.

Patellar Tendon Tears

patellar1-300x300Anatomy
The patellar tendon attaches the lower pole of the kneecap (patella) to the lower leg bone (tibia). The quadriceps muscle attaches to the upper pole of the kneecap and pulls through the kneecap and patellar tendon to allow one to straighten out ones leg or to support ones weight while squatting.

When the patellar tendon is torn, one cannot support their weight when the knee is bent, such as getting up from a chair or going down the stairs.

Injury Mechanism
The patellar tendon is usually injured with a sudden high force across the tendon, such as landing from a jump. The patellar tendon can be injured by a direct blow or a sharp laceration across the tendon.

Symptoms
Patellar tendon injuries present as significant pain across the front of the knee and immediate weakness in supporting ones weight while squatting. Patients usually cannot straighten their knee out fully with a complete tear of the patellar tendon. Rapid swelling occurs. Often, one can feel a gap under their kneecap at the site of the rupture.

Diagnosis
patellar2-300x235The physician’s work-up will start with a careful history and exam. The physician can often feel the defect in the patellar tendon and can appreciate the weakness on trying to straighten out the knee against resistance.

X-rays reveal a very high riding patella, since the pull of the quadriceps is no longer opposed by the tethering effect of an intact patellar tendon.

An MRI scan is often obtained to confirm the diagnosis, especially if the physician is concerned that the injury may be just a partial tear that may be able to heal without surgical repair. Plain x-rays show the bones of the knee, while MRI scans reveal the soft tissues around the knee including the ligaments, menisci, muscles and tendons.

Treatment
Your physician will discuss treatment options with you. Treatment decisions are based on whether the injury is a complete tear or a partial tear. Partial tears may be able to be treated with a brace. The brace is initially locked out completely straight to take all of the pressure off of the injured tendon.

As healing occurs, the hinges are unlocked and motion and strengthening are initiated. With complete tears, surgery is almost always recommended. Surgery involves sewing the two ends of the tendon together with strong suture material. If the tendon has pulled directly off of the bone, drill holes are made into the bone to repair the tendon directly to the bone. Risks and benefits of surgery are discussed thoroughly with the patient.

What to expect after surgery
Patellar tendon surgery is usually performed as an outpatient procedure. Patients are sent home with crutches and a knee brace with the knee fully straightened to protect the repair. Depending on the strength of the repair, patients start gentle range of motion and progressive weight bearing over 6-8 weeks.

Patients are using a stationary bike by 2 months, and an elliptical or stair climber shortly thereafter. Jogging is restricted until 4 months following surgery and full sports activities are not resumed until 6 months after surgery. Most patients can return to full activities, with no restrictions and no bracing at the 6th month point.

Knee Pain and Skiing

Knee pain is a common complaint among skiers, and often knee pain in skiers is the result of an injury. The location and severity of the pain depends on the cause of the problem. Signs and symptoms that often accompany knee pain include redness, warmth, weakness, instability, swelling, stiffness, œlocking, and œpopping.

Be sure to notify your orthopedic specialist if you have knee pain accompanied with swelling, cannot fully extend of flex your knee, notice a deformity, have a fever, or if the knee œgives out.

Knee Injuries from Skiing

Because of the mechanics of the sport, knee injuries are quite common for skiers. These injuries can range from simple to complex, with 25% of all ski injuries affecting the knee.

MCL Injury – The most commonly injured knee structure is the medial collateral ligament (MCL). This is because of the type of stance and turn skiers use that places serious stress on the inside of the knee.

ACL Injury – The anterior cruciate ligament (ACL) is injured in more advanced skiers or from those who have a specific type of fall. ACL injuries are associated with sudden direction change with a twisting injury accentuated by the long lever arm of the ski.

Torn Meniscus – Another common skiing injury is a torn meniscus. The meniscus is a rubbery tough cartilage that acts a shock absorber for the joint. It is torn when you suddenly twist your knee with weight on it or from a direct contact blow during a fall.

Knee Bursitis – Certain knee injuries lead to inflammation of the bursae, the small sacs of fluid that cushion the knee joint. This condition is painful, especially with bending of the knee, and swelling is common.

Patellar Tendinitis – When one or more tendons are irritated and inflamed, patellar tendinitis develops. The tendons are the thick fibrous cords that attach bone to muscle. Skiers are prone to inflammation of this tendon that connects the quadriceps muscle on the front of the thigh to the tibia (shinbone).

Knee Dislocation – Pain from dislocation of the knee joint is rare and is a true emergency. The displacement of the leg stretches and tears the knee ligaments and may involove injuries to the arteries and/or nerves. This painful condition often produces an obvious knee deformity and requires immediate medical attention.

Kneecap (Patella) Dislocation – Dislocation of the patella is caused from direct trauma or forceful twisting of the knee. Obvious patella deformity occurs with this condition, and you should seek medical care immediately.

Runner’s Knee (Patellofemoral Pain)

Skiers put heavy stress on their knees that causes a condition called runner’s knee. This knee pain syndrome causes pain around the front aspect of the knee. The pain occurs with walking up or going down stairs, squatting, kneeling, or sitting.

Patellofemoral pain is caused by malalignment of the knee, partial dislocation, injury, flat feet, or tightness and weakness of the thigh muscles. Runner’s knee can be the result of soft tissue irritation in the front of the knee.

Treatment for Knee Pain

Treatment of your knee pain will depend on the particular problem that is causing the pain.

Basic First Aid for Knee Pain

Stop skiing and use the RICE formula:

Rest – Avoid putting weight on the painful knee.

Ice – Apply cold packs or ice wrapped in a towel for short intervals of time frequently.

Compression – Use an elastic bandage, like a simple knee sleeve with the kneecap cut out that fits snugly.

Elevation – Keep the knee raised up higher than your heart.

Nonsurgical Treatment

If you have knee pain, you should see an orthopedic specialist. The doctor may recommend physical therapy for you to learn reconditioning to regain full range of motion, power, strength, speed, and endurance. These exercises help the front thigh muscles (quads) and the back thigh muscles (hamstrings).

Another thing the doctor may recommend is a special brace to help protect and support the knee. Certain knee pain syndromes respond to injections of corticosteroids to reduce inflammation. The doctor may recommend a hyaluronic acid injection for joints that need extra lubrication.

Surgical Treatment

There are several surgical knee procedures for knee pain.

Arthroscopy – This is done when there is significant damage to the cartilage or meniscus. The orthopedic specialist uses a pencil-sized instrument (called an arthroscope) to look inside the knee joint to diagnose and repair your condition.

Realignment – This is done to reduce the pressure on the cartilage and supporting structures of the front aspect of the knee.

Partial Knee Replacement Surgery – This procedure is done when there is serious damage to the knee. The orthopedic specialist replaces the damaged portion with parts made of metal and plastic.

Total Knee Replacement – This surgery is done when the doctor must remove significant damaged bone and cartilage and replace it with an artificial joint.

Knee Pain Prevention

Keep weight normal – Maintaining a healthy weight is the best thing you can do to prevent knee pain and injury.

Get strong and stay limber – Weak muscles lead to knee injuries, so keep your quads and hamstrings strong. Balance and stability training allows the muscles of the knees to function properly. Also, avoid injury by stretching to increase flexibility.

Stay in shape – Prevent knee pain and injury by keeping yourself well-conditioned.

Use proper gear – Make sure your skiing shoes are good shock absorbers and of quality construction. Also, be sure your shoes fit properly.

Plica Syndrome of the Knee

Plica syndrome of the knee occurs when synovial tissue bands become irritated from injury or overuse. Pieces of synovial plica are remnants from early fetal development. These plica are membranes that should normally diminish during the second trimester of fetal development. When the pouches do not combine to form a synovial cavity, the plica remain in the knee as bands of synovial tissue.

Plica syndrome of the knee is associated with chronic overuse, inflammatory conditions, and knee injury. The medial plica is one of the four plica that are found in the knee. This piece of the lower end of the kneecap runs sideways and attaches to the lower aspect of the thighbone.

How does a plica cause problems in the knee?

A plica that becomes irritated causes knee pain. This occurs as a result of repetitive motions, certain exercises, or from kneeling. Any activity that causes repetitive bending and straightening of the knee can cause knee plica syndrome, such as stair-climbing, running, or biking. When the knee is struck near the medial plica from a fall or car accident, knee plica syndrome can develop. These types of injuries cause the plica and the tissue around it to swell and become painful.

What are the signs and symptoms of plica syndrome?

The main symptom of plica syndrome is pain. There is frequently a snapping sensation along the inside aspect of the knee when it is bent. This is caused by the rubbing of the thickened plica over the edge of the thighbone where it enters the joint. The knee may also be tender to touch and swollen.

How is plica syndrome diagnosed?

The orthopedic specialist diagnoses plica syndrome during a physical examination or at an arthroscopic surgery procedure. X-rays, a CT scan, and/or a MRI may be done to rule out other problems. X-rays rule out fractures, and the MRI shows soft tissue injuries. The CT scan can detect a thickened plica in some cases. To confirm the diagnoses and treat the problem at the same time, the orthopedic specialist may perform an arthroscopy.

What is the treatment for plica syndrome?

Our orthopedic specialists treat plica syndrome by resting the knee joint and with anti-inflammatory medications. If these conventional measures do not ease the pain of the knee, the doctor may inject cortisone into the joint.

Cortisone is a powerful anti-inflammatory agent. For serious cases of plica syndrome, surgical removal of the plica may be necessary. This procedure is done with an arthroscope, using a small camera and tiny instruments to remove the inflamed tissue.

The area left once the plica is removed heals with minimal scarring. Plica resection is often needed. The goal of treatment is to reduce the inflammation and restore function.

What is involved with the rehabilitation process?

If your doctor treats you non-surgically, you should return to normal activity within 4 to 6 weeks. It may be necessary for you to see a physical therapist during this time to learn stretching and strengthening exercises.

Other therapies include friction massage, ultrasound, and ice applications, all done to decrease the inflammation associated with plica syndrome. If you have surgery, you will need physical therapy to help you regain strength and function.

Frequently Asked Questions About Arthroscopy

Arthroscopy FAQs

Arthroscopy is a detailed surgical procedure that allows your orthopedic specialist to look at the inside of a particular joint through a viewing instrument called an arthroscope. During this procedure, the doctor looks at the joint surfaces, as well as the other structures within the joint, such as the cartilage and ligaments. An arthroscopic examination allows the doctor to make a tiny incision in your skin and insert a pencil-sized instrument. The arthroscope has a small lens and lighting system used to illuminate and magnify the joint structures. The doctor can then visualize your joint on a TV monitor.

What does the word ‘arthroscopy’ mean?

The word ‘arthroscopy’ is derived from two separate Greek words, ‘arthro’ meaning joint, and ‘skopein’ meaning to look in. The term literally means “to look in the joint”.

Why is arthroscopy necessary?

The orthopedic specialist uses arthroscopy for diagnosis and repair. Some injuries can be diagnosed with x-rays, magnetic resonance imaging (MRI), or computed tomography (CT). Other injuries, however, require further diagnostic techniques. The arthroscope allows the surgeon to make a more accurate final diagnosis and repair the injury at the same time. Some of the common conditions found during arthroscopy include:

  • Inflammation: Swelling and redness of the lining of the shoulder, elbow, wrist, knee, or ankle
  • Shoulder: Injury to the rotator cuff tendon, injury to the biceps tendon, impingement syndrome, and recurrent dislocations
  • Knee: Meniscus tears, chondromalacia, and anterior cruciate ligament tears as well as evaluating damage to the joint surfaces
  • Wrist: Torn cartilage or loose bodies
  • Loose Bodies of Bone or Cartilage

What are some problems treated with arthroscopy?

The problems treated with arthroscopy include:

  • Reconstruction of the anterior cruciate ligament of the knee
  • Rotator cuff surgery
  • Removal of lose bone or cartilage
  • Repair of torn ligaments
  • Removal of inflamed synovium lining of the shoulder, knee, elbow, ankle, or wrist
  • Repair or removal of a torn meniscus of the knee

What joints are most frequently examined by arthroscopy?

There are six joints that are typically examined with the arthroscope. These include the knee, shoulder, elbow, ankle, hip, and wrist.

How is arthroscopy performed?

Arthroscopic surgery is less traumatic than traditional open surgery. The orthopedic specialist uses general or regional anesthesia, depending on which joint and the extent of the problem. A small, buttonhole sized incision is made on the skin to insert the arthroscope along with several other small incisions around the joint area.

The surgeon inserts the instruments through this incisions and uses the additional incisions to insert specially designed instruments used for repair. When indicated, the surgeon corrects the problem and repairs the damage as necessary.

After the procedure, the small incisions are closed with sutures or Steri-strips and covered with a dressing. You will be moved from the operating room to the recovery room. Most arthroscopic procedures are done on an outpatient basis.

Before you are discharged to home, you will be given instructions about how to care for your wounds, what activities to avoid, and which exercises to perform to aid your recovery. The sutures will be removed during your follow-up visit.

What are the possible complications of arthroscopy?

Although complications are rare, they do occasionally occur following arthroscopy. These include blood clots of a vein, infection, excessive swelling, bleeding, damage to blood vessels or nerves, and muscle damage.

What are the advantages of arthroscopy?

Arthroscopic surgery allows quicker recovery time and less pain because less muscle and tissue are disturbed during the procedure, as compared to traditional open surgery. Most patients are treated as outpatients and are home several hours after the operation.

What is recovery like after arthroscopy?

The small incisions take several days to heal. The orthopedic specialist will instruct you as to when the surgical dressing can be removed. The pain in the joint is minimal but may take several weeks to maximally recover. The orthopedic specialist will develop a tailored rehabilitation plan for you to follow. This will depend on the joint that was worked on, the degree and severity of your injury or condition, and your current health status. Most athletes are able to return to their usual athletic activities within a few weeks, and other patients return to normal activities in a short time.

How does arthroscopy feel?

If you are given a general anesthetic, you will be unconscious and not feel anything during your operation. If you receive regional anesthesia, your arm or leg will be numb for several hours. You will not feel anything during the procedure either.

Expect to have some mild soreness and pain following your arthroscopic procedure. The orthopedic specialist will prescribe some pain medicine for you to use, and advise you to apply ice to your joint. This helps reduce pain and swelling. Be sure to keep your bandages clean and dry while the joint heals.

Common Causes of Knee Pain and When to Seek Treatment

The knee is the largest joint of the body, and it is also the one most easily injured. The knee is made up of the lower end of the femur (the thigh bone), the upper end of the tibia (the shin bone), and the patella (the knee cap). Large ligaments support the knee, provide stability, and connect the bones. Other important structures include the meniscus (a cushion of cartilage), muscles, nerves, and blood vessels.

Knee injuries cause knee pain, especially for athletes. There are four major ligaments of the knee: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). Also, the meniscus is commonly injured, resulting in knee pain. Other causes of knee pain include Osgood-Schlatter Disease and Adolescent Anterior Knee Pain.

ACL Injury

The ACL extends from the front of the tibia and inserts on the back of the femur. This structure prevents excessive posterior movement of the femur on the tibia. The ACL is often torn when an athlete changes direction rapidly, slows down from running, or lands wrong from a jump. These types of injuries are common for athletes who ski, play basketball, or play football. The pain associated with a torn ACL is rated as moderate to severe and is typically described as sharp at first, and then throbbing or achy as the knee begins to swell. Most people report increased pain with bending or straightening of the knee.

PCL injury

PCL injuries are much less common compared to ACL injuries.  The PCL is often injured when an athlete receives a blow to the front of the lower leg, just below the knee or makes a simple misstep on the playing field. The PCL prevents the tibia from sliding backwards and works with the ACL to prevent pivoting of the knee. The symptoms of a PCL tear include knee pain, decreased motion, and swelling.

MCL Injury

Most injuries to the MCL are the result of a direct blow to the outside of the knee. Athletes who play soccer or football are at increased risk for this type of injury. The MCL spans the distance from the top of the tibia to the end of the femur on the inside of the knee. This structure prevents widening of the inside of the joint. A torn MCL causes swelling over the ligament, bruising, and feeling that the knee will give out or buckle.

LCL Injury

The LCL connects the end of the femur to the top of the fibula (the smaller shin bone). It is located on the outer aspect of the knee. The LCL helps to prevent unnecessary side-to-side movement of the knee joint. The LCL is usually torn from traumatic falls, motor vehicle accidents, or during sporting activities. Symptoms of a torn LCL depend on the severity of the tear and include pain, swelling, difficulty bending the knee, and instability of the joint.

Torn Meniscus

The meniscus is the rubbery, tough cartilage that sits between the femur and the tibia. This structure works as a shock absorber. Athletes are at risk for tears in this cartilage with cutting, pivoting, twisting, decelerating, or being tackled. There are two menisci of the knee and they lie between the femur and tibia, one on the inside and one on the outside of the joint. The symptoms of a meniscus tear include knee pain, swelling, popping sound within the knee, and limited motion of the joint.

Osgood-Schlatter Disease

Osgood-Schlatter disease is an overuse injury common among growing adolescents. This syndrome is caused by inflammation of the tendon below the patella. Athletes who participate in gymnastics, basketball, running, and soccer are at increased risk for this disease. The symptoms of Osgood-Schlatter disease include swelling, knee pain, and tenderness below the knee cap.

Adolescent Anterior Knee Pain

Young, active adolescents often complain of pain in the front and center region of the knee. This is called Adolescent Anterior Knee Pain, and it is not associated with any injury or damage to the knee structures. The cause of this syndrome is not clear, but experts believe that the complex anatomy of the knee joint contributes to the problem. The knee is extremely sensitive to problems of alignment and overuse. For teens, a number of factors are thought to be involved. These include poor flexibility, imbalance of the thigh muscles, problems with alignment, improper sports training techniques, improper use of equipment, and overdoing sports activities.

Symptoms of Adolescent Anterior Knee Pain include pain that begins gradually and is worse at night, popping sounds of the knee when climbing stairs or walking after prolonged sitting, pain during activities that repeatedly bend the knee, pain that causes the knee to buckle, and pain related to change in activity level or playing surface.

When to Seek Treatment

Seek medical attention immediately if you:

  • Have severe knee pain
  • Begin limping
  • Notice swelling at the site of injury
  • Hear a popping or clicking noise
  • Feel that your knee is going to give out
  • Cannot move your knee
  • Cannot bear weight on your knee
  • Have tenderness along any aspect of the knee or tibia
  • Have pain with climbing stairs, walking, or running