Knee Pain and Homoeopathy

by

Dr. Rajneesh Kumar Sharma

© Dr. Rajneesh Kumar Sharma

Homoeo Cure & Research Centre P. Ltd.

NH 74- Moradabad Raod, Kashipur

Uttaranchal – INDIA - 244713

Article outline-

Introduction- Key words- Knee anatomy- Common knee disorders and their miasmatic analysis- Homoeopathic Treatment

Introduction

Knee joint pain is a very common complaint, being not only uncomfortable but causing lot of anxiety. It is often associated with ageing process but no age is immune. To study knee pain, one must be acquainted with anatomy of knee joint.

Key words-

Osteoarthrosis-

This is the form of arthritis characterized by erosion of articular cartilage, either primary or secondary to trauma or other conditions. The articular cartilage becomes soft, frayed, and thinned with eburnation of subchondral bone and outgrowths of marginal osteophytes. It results in pain and loss of function and mainly affects weight-bearing joints. It is more common in older persons.

Rheumatoid arthritis-

It is a systemic disease, occurring more often in women, which affects connective tissue. Arthritis is the dominant clinical manifestation, involving many joints, especially those of the hands and feet, accompanied by thickening of articular soft tissue, with extension of synovial tissue over articular cartilages, which become eroded. Its course is variable but often is chronic and progressive and it often leads to deformities and disability.

Ankylosing spondylitis-

This is the arthritis of the spine, resembling rheumatoid arthritis that may progress to bony ankylosis with lipping of vertebral margins. This disease is more common in the male often with the rheumatoid factor absent and the HLA antigen present. There is a striking association with the B27 tissue type and the strong familial aggregation suggest an important genetic factor, perhaps inherited as an autosomal dominant, the mechanism, however, remains obscure.

Psoriatic arthritis-

It is the concurrence of psoriasis and polyarthritis, resembling rheumatoid arthritis but thought to be a specific disease entity, seronegative for rheumatoid factor and often involving the digits.

Rickets-

It is a disease due to vitamin-D deficiency and characterized by overproduction and deficient calcification of osteoid tissue. It is associated with skeletal deformities, disturbances in growth, hypocalcemia, and sometimes tetany. It is usually accompanied by irritability, listlessness, and generalized muscular weakness. In this disese, fractures are frequent.

Osteoporosis-

This is a condition of reduced bone mass, with decreased cortical thickness and a decrease in the number and size of the trabeculae of cancellous bone (but normal chemical composition). It results in increased fracture incidence. Osteoporosis is classified as primary (Type 1- postmenopausal osteoporosis; Type 2- age-associated osteoporosis; and idiopathic, which can affect juveniles, premenopausal women, and middle-aged men) and secondary osteoporosis (which results from an identifiable cause of bone mass loss).

Gout-

It is a disorder of purine metabolism, occurring especially in men, characterized by a raised but variable blood uric acid level and severe recurrent acute arthritis of sudden onset resulting from deposition of crystals of sodium urate in connective tissues and articular cartilage. The most cases are inherited, resulting from a variety of abnormalities of purine metabolism. The familial aggregation is for the most part galtonian with a threshold of expression determined by the solubility of uric acid. However, gout is a feature of the Lesch-Nyhan syndrome an X-linked disorder.

Osteomalacia-

It is also called as adult rickets. It is a disease characterized by gradual softening and bending of the bones with varying severity of pain. The softening occurs because the bones contain osteoid tissue which has failed to calcify due to lack of vitamin D or renal tubular dysfunction. It is more common in women than in men. Osteomalacia often begins during pregnancy.

Paget’s Disease-

It is a generalized skeletal disease, frequently familial, of older persons in which bone resorption and formation are both increased, leading to thickening and softening of bones (e.g., the skull), and bending of weight-bearing bones.

Pseudogout-

Acute episodes of synovitis caused by deposits of calcium pyrophosphate crystals rather than urate crytals as in true gout; associated with articular chondrocalcinosis is called as pseudogout.

Tibia vara or Genu varum -

It is a deformity marked by medial angulation of the leg in relation to the thigh or an outward bowing of the legs.

Genu valgum or Knock knees -

It is a deformity marked by lateral angulation of the leg in relation to the thigh.

Tumours of Knee-

These may be benign or malignant. Malignant ones may be metastatic. viz. osteosarcoma, Eving’s sarcoma etc.

Anatomy of the Knee Joint

Articular Surfaces

The articular surfaces are most incongruent.

• The femoral condyles, bearing articular cartilage, are almost wholly convex.
• The tibial surfaces are also cartilage-covered areas, separated by the intercondylar region. Each region is gently hollow centrally and flattened peripherally where the meniscus rests.
• The lateral tibial articular surface is almost circular and smaller and the medial oval.
• Patella is the largest seasamoid bone in the body. Its articular surface is adapted to the femoral surface which extends onto the anterior surfaces of both condyles like an inverted U. As the knee extends, the middle patellar facets contact the lower half of the femoral surface; in full extension only the lowest patellar facets are in contact with the femur. Ligaments of the joint are the patellar ligament (ligamentum (tendo) patellae), tibial and fibular collateral, oblique and arcuate popliteal, anterior and posterior cruciate and transverse ligaments.

Fibrous Capsule

The fibrous capsule is complex, partly deficient and partly augmented by expansions from adjacent tendons. Internally the capsule is attached to the meniscal rims, connecting them to the tibia by short coronary ligaments.

Synovial Membrane

It is the connective tissue membrane that lines the cavity of a synovial joint and produces the synovial fluid; it lines all internal surfaces of the cavity except for the articular cartilage of the bones. The synovial membrane of the knee is the most extensive and complex in the body.

Bursae

Bursae associated with the knee are numerous.

Anteriorly there are:

• A large subcutaneous prepatellar bursa between the lower patella and skin.
• A small deep infrapatellar bursa between the tibia and patellar ligament.
• A subcutaneous infrapatellar bursa between the distal part of the tibial tuberosity and skin.
• A large suprapatellar bursa between the femur and quadriceps femoris.

Laterally there are:

• A bursa between the lateral head of gastrocnemius and joint capsule (sometimes continuous with the joint).
• One between the fibular collateral ligament and the tendon of biceps femoris.
• One also between the fibular collateral ligament and the tendon of popliteus.
• One between the tendon of popliteus and the lateral femoral condyle, usually an extension from the joint.

Medially there are:

• A bursa between the medial head of gastrocnemius and fibrous capsule.
• A bursa between the tibial collateral ligament and the tendons of sartorius, gracilis and semitendinosus.
• Variable bursae, in number and position, deep to the tibial collateral ligament between the capsule, femur, medial meniscus, tibia or tendon of semimembranosus.
• A bursa between the tendon of semimembranosus and the medial tibial condyle and also the medial head of gastrocnemius (the semimembranosus bursa).
• An occasional bursa between the tendons of semimembranosus and semitendinosus.

Posteriorly, bursae are variable.

The ligaments of the knee

The cruciate, collateral, posterior and capsular ligaments and the menisci form an integrated stabilising system which prevents the tibia from shifting or tilting under the femur in an abnormal fashion.

Patellar Ligament (Ligamentum Patella)

This is the central band of the tendon of quadriceps femoris, continued distally from the patella to the tibial tuberosity. It is strong, flat, about 8 cm in length, attached-

• Proximally to the apex, adjoining margins and to rough areas on the anterior surface and on the depression on the distal posterior patellar surface, and
• Distally to the superior smooth area of the tibial tuberosity.
• The patellar ligament is separated from the synovial membrane by a large infrapatellar fat pad and from the tibia by a bursa.

Oblique Popliteal Ligament

It expands from the tendon of semimembranosus, blends partly with the capsule and ascends laterally to the lateral part of the intercondylar line and lateral femoral condyle. It is in the floor of the popliteal fossa with the popliteal artery in contact.

Arcuate Popliteal Ligament

It is Y-shaped mass of capsular fibres, having a stem attached to the head of the fibula.

Tibial Collateral Ligament

It is a broad flat band nearer the back of the joint. It extends from the medial femoral epicondyle, immediately distal to the adductor tubercle, to the medial meniscus, tibial condyle and adjacent shaft.

Fibular Collateral Ligament

It is a strong cord, attached to the lateral femoral epicondyle, proximal to the popliteal groove. It extends to the fibular head in front of its apex. The ligament is not attached to the lateral meniscus.

Cruciate Ligaments

They are very strong and sited a little posterior to the articular centre. They are termed cruciate because they cross, anterior and posterior from their tibial attachments. This are-

• The Anterior Cruciate Ligament, attached medially to the anterior intercondylar area of the tibia partly blending with the anterior horn of the lateral meniscus.
• The Posterior Cruciate Ligament, stronger, less oblique with some shorter fibres, attached to the posterior intercondylar area and posterior horn of the lateral meniscus.

Transverse Ligament

It connects the anterior convex margin of the lateral to the anterior horn of the medial meniscus; it varies in thickness and may be absent.

Menisci

The menisci (semilunar cartilages) are crescentic laminae deepening the articulation of the tibia which receives the femur. Their peripheral attached borders are thick and convex; their free borders are thin and concave. The proximal surfaces are smooth and concave, in contact with the articular cartilage on the femoral condyles, while their distal surfaces are smooth and flat, resting on the tibial articular cartilage.

Menisci probably assist lubrication, facilitate combined sliding, rolling and spinning, and may cushion extremes of flexion and extension. Menisci are-

• Medial Meniscus- Broader behind, it is almost a semicircle.
• Lateral Meniscus- About four-fifths of a circle and covers a larger area than the medial meniscus.

Vessels and Nerve Supply to the Joint

Arteries supplying the joint are-

• the descending genicular branches of the femoral
• superior, middle and inferior genicular branches of the popliteal
• anterior and posterior recurrent branches of anterior tibial
• the circumflex fibular artery and
• the descending branch of the lateral circumflex femoral.

Nerves are from the-

• Obturator
• Femoral
• tibial and
• Common peroneal nerves.

The extensor mechanism of the knee

Extension of the knee is produced by the quadriceps muscle acting through the quadriceps ligament, patella, patellar ligament and tibial tubercle.

• Weakness of extension- It leads to instability, repeated joint trauma and effusion. There is often a vicious circle of pain-

→quadriceps inhibition →quadriceps wasting →knee instability →ligament stretching and further injury →pain.

• Loss of full extension- It also leads to instability, as there is failure of the screw-home mechanism. Rapid wasting of the quadriceps is seen in all painful and inflammatory conditions of the knee.

Weakness of the quadriceps is also sometimes found in lesions of the upper lumbar intervertebral discs, as a sequel to poliomyelitis, in multiple sclerosis and other neurological disorders, and in the myopathies. Quadriceps wasting may be the presenting feature of a diabetic neuropathy or secondary to femoral nerve palsy from an iliacus haematoma.

The term ‘jumper’s knee’ is used to describe a number of conditions where there is pain in the patellar ligament or its insertion: it includes the -

Sinding–Larsen–Johansson syndrome- seen in children in the 10–14 age group, where there are X-ray changes in the distal pole of the patella.

Osgood Schlatter’s disease- (often thought to be due to a partial avulsion of the tibial tuberosity) which occurs in the 10–16 age group. In it there is recurrent pain over the tibial tuberosity, which becomes tender and prominent. Radiographs may show partial detachment or fragmentation. Pain generally ceases with closure of the epiphysis. In an older age group (16–30) the patellar ligament itself may become painful and tender. This almost invariably occurs in athletes, and there may be a history of giving-way of the knee. CT scans may show changes in the patellar ligament, the centre of which becomes expanded.

Following table summarizes the main causes of knee joint pain.

Common causes of knee pain

Homoeopathic Treatment-

The symptoms with Knee Pain in various repertories-