10,000 Steps A Day

That's how far you must walk to meet government guidelines for physical activity to improve health. But if, like millions of people, you find walking painful or you fear your joints might buckle beneath you, each step might as well be a mile.

Significant and persistent knee pain affects nearly 25% of women and 20% of men. Your knees and hips -- your largest joints -- support your body's weight while allowing your legs to move freely. Even walking at a leisurely pace puts a force that is double your body weight on each leg. Running or descending stairs quadruples that force. Our first article discusses two common overuse injuries of the knee: Bursitis and Tendonitis.

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Common overuse injuries of the knee

The knee has been likened to an expensive sports car -- a finely tuned machine that is capable of great power, but also highly vulnerable to breakdown. Over time, many things can go awry as a result of illness, mishap, and misuse of the joint. Overuse injuries occur over a period of time rather than after a single injury or illness. They may result from repeated overwork. As we age, they become more common.

Two common overuse injuries of the knee are bursitis and tendonitis. Small fluid-filled sacs called bursae cushion the movement of bones against muscle, skin, or tendons. Bursitis occurs when one or more of these sacs become inflamed. Irritation from prolonged kneeling can result in bursitis involving either the sac that lies between the front of your kneecap and your skin (called prepatellar bursitis or "housemaid's knee") or the bursa just below the kneecap (called infrapatellar bursitis). People who kneel on the job or during prolonged gardening and housecleaning are susceptible to these forms of bursitis.

You may also develop prepatellar bursitis if you hit the front of your knee in an accident or diving to the floor playing sports.

Pes anserine bursitis
[ http://www.med.umich.edu/1libr/sma/sma_pesanser_art.htm ]

involves the lubricating sac between your shinbone and the hamstring tendons at the inside of your knee. Just walking may stress the pes anserine bursa if you are obese, have tight hamstring muscles, have knees with a natural turnout, or have changed how you walk in response to another type of joint damage (such as osteoarthritis).

Runners are susceptible, particularly if they neglect to stretch and warm up properly, if they quickly increase their mileage, or if they train on hills. Repeatedly kicking a ball also irritates this bursa. To check for bursitis, your doctor touches the bursa to detect tenderness. He or she may inject a bit of local anesthetic into the sac. If the pain disappears, that's strong evidence of bursitis. You may need imaging tests to distinguish pes anserine bursitis from other conditions.

If you have symptoms of infection (fever, persistent redness, rash, or swelling) your doctor may withdraw a little fluid from the bursa to check for bacteria. Infection is very uncommon in the pes anserine bursa, but the prepatellar bursa can become infected in people who spend a lot of time on their knees.

Symptoms of bursitis include:
* swelling in front of the kneecap (prepatellar) or underneath the kneecap (infrapatellar)
* warmth and tenderness
* pain when you bend or straighten your knee.

Pes anserine bursitis may cause distinctive pain as follows:
* pain located a few inches below the kneecap, in the center of it, or behind it
* increase in pain when you climb stairs or exercise
* pain that radiates to the back and inside of your thigh
* pain when your knees touch as you lie on your side.

Bursitis is treated with rest, ice, and compression to reduce swelling. To relieve pain, doctors typically recommend an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin, and others) or naproxen (Aleve, Anaprox, and others).

You'll also need to avoid activity that aggravates the condition during the healing process, which usually lasts two to six weeks. If the fluid in the bursa shows signs of infection, you'll need to take antibiotics, and the doctor may remove fluid daily. In extreme cases, the swollen bursa is removed surgically.

Your doctor may also recommend physical therapy. Physical therapy focuses on strengthening and stretching the quadriceps and inside hamstrings. A physical therapist can also show you how to protect your knee in sports and daily activities. If your normal stance puts pressure on the pes anserine bursa, using flexible, over-the-counter arch supports in your shoes may reduce it.

To prevent prepatellar bursitis, wear protective kneepads (such as roofer's pads or gardening pads) while kneeling or while playing sports likely to involve hitting the knees. Bursitis can recur if you don't take preventive measures after it heals.

Patellar Tendonitis (Jumper's Knee)

http://www.med.umich.edu/1libr/sma/sma_jumpersk_art.htm

Tendonitis is inflammation in a tendon, usually the result of overuse. The affected tendon continues to function, at least for a while, but there is recurrent pain. You may develop tendonitis if you launch into high-intensity activities such as running or basketball on the weekend, while doing little to maintain your conditioning during the week.

With age, tendons become stiffer and more prone to tendonitis, while supporting muscles become weaker and less able to provide protection. Inflexible hamstrings and quadriceps make someone more susceptible. Tendonitis in the knee can occur in the patellar tendon (most common) or the quadriceps tendon. Dancers, runners who are training vigorously, and athletes who jump a lot are subject to patellar tendonitis, sometimes called "jumper's knee."

Symptoms of tendonitis include:
* pain above or below the kneecap where the tendons attach to bone
* swelling
* pain that recurs with particular activities and eases with rest
* in severe cases, pain that no longer improves with rest.

For the first few days, tendonitis is treated with rest, ice, NSAID pain relievers such as ibuprofen (Advil or Motrin) or naproxen (Aleve or Anaprox), and often a knee support. After that, you can resume gentle activities that don't aggravate the area. If pain doesn't improve with rest, your doctor may apply a steroid solution over the area and use electrical stimulation to help the medication reach the tendon and reduce inflammation.

Surgery is sometimes performed to remove abnormal areas of the tendon, but there are many unanswered questions about the benefits and proper uses of this approach. Rehabilitation for tendonitis includes exercises to improve flexibility and address muscle imbalances that place extra stress on the tendons. You can usually resume normal activities in a few days and more demanding athletic activities in a few weeks, after the pain and swelling are gone and you have regained muscle strength.

Excerpted from Knees and Hips: A Troubleshooting Guide to Knee and Hip Pain published by Harvard Medical School. http://www.health.harvard.edu/hhp/publication/view.do?name=KH.

REFERRED KNEE PAIN
Pain felt in the knee NOT caused by a problem in the knee.

Referred knee pain may be the result of a herniated disc in the back, arthritis in the hip or even clots in the leg. It is important to distinguish pain that arises from knee pathology from other potential causes.

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A pinched nerve for example may result in pain behind the knee and a torn piece of cartilage inside the may cause pain in the front of the knee. These two problems together can lead to pain that is felt all over the knee.

Referred knee pain must be a diagnosis of exclusion meaning that other causes of pain must be ruled out first. So, initially your doctor may carefully evaluate you for problems associated with your knee. A detailed history asking about back, hip or leg pain will also be done looking for other causes. If a specific anatomic area (such as the back) needs further evaluation, x-rays or perhaps MRI scanning may be done.