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Painful Knee Conditions

Most of the painful knee conditions of which patients complain are not
directly due to true pathological conditions either of the knee joint
itself or of its neighboring structures, but rather to affections of
other portions of the leg that set a special strain upon the knee and,
above all, to various kinds of foot disturbances. The erect position
is maintained principally by a nice balance of nervous and muscular
energy in the knee joint and its surrounding structures. Any irregular
sensory or motor impulses to the knee-joint or to the muscles of the
thigh will disturb the absolute equilibrium of the flexors and
extensors and will make standing painful or even impossible. Whenever
a morbid condition requires a different use of the muscles and tendons
around the knee from that to which they are accustomed, fatigue
readily ensues, and aches and even tenderness in muscles and tendons
develop as the result of the over-exertion. These collateral
conditions must not be overlooked in the diagnosis and treatment of
painful knee conditions.

Etiological Factors.--Even a slight sore on one foot will give rise to
considerable achy fatigue of the knee of the opposite leg, because,
consciously or unconsciously, we stand much more on that leg, use it
more in walking, and spare the other because of the pain induced by
use of the foot. Above all, throwing more weight on the other leg
causes us to use muscles a little abnormally with consequent soreness.
This painful fatigue is most likely to be felt around the knee, though
it may extend to the hip and even the lumbar region of the well
side if the foot continues to be spared for a number of days.
Particularly will this be true if there is anything the matter with
the big toe, on which so much of the use of the foot depends. An
ingrowing toenail will not infrequently give so much discomfort to the
well knee and hip as to make the patient sure that there must be some
rheumatic or other condition at work in these joints. The serious
affection of the joint which the patient apprehends is found to be no
more than a sympathetic fatigue induced by having to use his feet, or
one of them, a little differently from usual, perhaps because of some
condition that leads him to spare them. To call the patient's
attention to this is of itself therapeutic.

Inequality of Legs.--The effort required for standing and the
accurate balance of the muscles involved in it is such that any
mechanical disturbance of the feet or legs or even a trivial
pathological condition causes painful fatigue. It must not be
forgotten, for instance, that the presumption that human limbs are of
exactly the same length is not confirmed by accurate measurements.
There is an average difference of probably half an inch in length
between the limbs of normal persons, and there may be even a
difference of more than an inch before deformity is said to be
present. The longer limbs are likely to do more work and are,
therefore, more subject to fatigue and consequent complaint. One of
the reasons why we can distinguish persons by their gait even at a
distance is that the difference in the length of their limbs makes
noteworthy characteristics in their walk.

High Heels.--People who are used to walking in a natural manner and
who don a pair of high-heeled shoes for the first time are sure to
complain of pain in the calf and knee, because the high heels require
them to hold the knee more rigid and in a somewhat different position
from that required when the persons stand under ordinary
circumstances. It is the unusual in muscular effort that gives rise to
the extreme fatigue which becomes positive pain if it is allowed to
continue. It is curious how small a raising of the heel will cause
discomfort. Over and over again I have known the careless putting on
of rubber heels to be responsible for pains around the knee, which in
damp weather were the source of so much discomfort that it was hard to
persuade the patient that he was not suffering from rheumatism or some
serious incipient pathological condition.

Unusual Occupations.--Joint pains often develop after the patient
has been doing something quite unusual and putting an unaccustomed
strain upon his muscles. I have often seen dispensary patients whose
knee pains began after there had been a family moving. In the course
of the removal of household goods, both men and women are likely to
help in hanging pictures, in taking them down, in moving heavy
furniture and other occupations of this kind which make them extremely
tired. If there is any tendency to relaxation of joint structures the
tiredness may manifest itself as a sense of painful discomfort. The
knees are particularly likely to suffer if there is a relaxed
condition anywhere in the leg. It must be remembered that the laxity
of tissue which predisposes a patient to weak or flat feet will have a
tendency to produce some looseness of fiber, at least, also in the
tissues around the knee. The patient may not have a wabbling knee, nor
may he be able to overextend the limb, but still there will usually be
some noticeable relaxation of the tissues which will help in the
production of the painful condition by making exaggerated calls
upon the muscles in order to keep the joint in proper position in
spite of the over motion in it.

The disturbance is most frequent in waiters, store clerks, tailors'
cutters and fitters, bench men in the trades, and in all those who
have to spend much time on their feet. I have seen many such ready to
give up their occupations, though they had no other resource and the
future looked very blank, indeed, away from their work. It was
difficult at first to persuade them that a slight yielding of the arch
had so changed mechanical conditions in the use of the muscles of the
leg as to produce such pains. But as soon as they were put in a
condition where their arch was not allowed to sink, they were at once
relieved of their discomfort to a great extent. The question of
treatment is discussed more fully in the chapter which follows on Foot

An interesting set of painful conditions around the knee develops in a
class of people in whom it might least be suspected of being due to
over-exertion connected with their occupations. These are lecturers,
clergymen, teachers, and others who, for several hours each day, are
on their feet in a position from which, as a rule, they do not move,
but stand almost perfectly quiet. A distinguished laryngologist has
pointed out that not infrequently men who come to be treated for the
chronic laryngitis, which is known as clergymen's sore throat, but
which is seen so frequently in those who have to talk in the open air,
auctioneers, cart-tail orators about election time, and in lecturers
to large audiences who do not know how to use the voice, also complain
of grievous discomfort from painful knee conditions which often makes
the ascent or descent of stairs a painful task. He attributes the
simultaneous occurrence of these conditions to some blood dyscrasia,
uric acid, or the like, affecting the two most used sets of muscles
and organs, the legs and the vocal cords. Whenever I have seen this
condition--and circumstances have brought me into intimate personal
relations with many clergymen and lecturers--the trouble at the knee
has been due to some yielding of the plantar arch, while the laryngeal
condition, if present, was due to an erroneous mode of using the voice
consequent upon lack of proper training.

Sufferers of this kind must be warned not to stand absolutely
immovable while addressing an audience. Some men stand without moving
during a whole hour's lecture. This is unfortunate, for it obstructs
the return circulation through the tense muscles, for the venous
circulation was intended to be helped by muscular contraction. Many a
man finds, as he comes down from pulpit or platform, that his knees
are stiff and sore, though a moment before he knew nothing about it.
The failure to notice any discomfort before is of itself an example of
the influence of the mind over the body for the relief of pain.

Associated Lumbar Discomfort.--The painful condition around the knee
which develops when high heels are worn is almost sure to be
accompanied by pains, or at least a tired feeling, in the back. If we
convince the patient that the trouble is due merely to a derangement
of the mechanism involved in maintaining the erect posture we shall
have scant need of medicine or even of local treatment. But as the
pain is much worse on rainy days, owing to the relaxation of the
muscles, we must be careful to remove the patient's suspicion that the
pain must have a rheumatic origin. The restoration of normal
mechanical conditions with the removal of the cause will prevent the
recurrence of the affection, and if some discomfort remains, the
patient will not worry, and the muscles will gradually grow accustomed
to the strain upon them. Of course, these conditions of discomfort are
more common in those who are not naturally strong, who are run down,
who are under-weight, or whose neurotic tendency will make any
irritation seem worse than it is.

Heavy and Light Patients.--Two classes are likely to suffer more than
others from these conditions. They are the people who are overweight
and the people who are underweight. Those who are overweight exert
much more effort to maintain the erect posture than ordinary people,
and, besides, in most adipose persons the distribution of weight is
such that a disproportionate amount of it is carried forward of the
normal center of gravity. High heels cause a further tilting forward
that has to be counter-balanced, and that, at least at the beginning,
gives rise to muscular discomfort. In people who are underweight the
nutrition of the muscles has suffered, and, as a consequence, they are
not able to support the frame as well as before. In them the
additional effort necessitated by the tilting tendency of high heels
is particularly felt because such people are nearly always among the
neurotically inclined.

Muscle Disuse.--Sometimes treatment of these conditions seems to lead
up to the disuse of certain muscles and the over-use of others. I
followed for several years an interesting case of this kind in which
the course of the affection was so typical as to deserve to be
recalled. A fuller account of the case occurs in my paper on
"Rheumatism versus Muscular and Joint Pains" in The American Journal
of the Medical Sciences, August, 1903.

In that case the joint symptoms caused by the pinching of a loose
cartilage within the joint occurred suddenly on two or three
occasions, so that a surgeon deemed it wise to put the knee in
plaster. As a consequence, some atrophy of the muscles of the leg
occurred, and a halt became habitual in the gait. Through this halting
gait, the muscles of the back on the same side were also spared and
thus became somewhat atrophied. Painful conditions developed in the
muscles of the other side of the back from the over-use necessary to
compensate for the condition on the less-used side. All of the muscles
on the affected side became painful, apparently because of the
atrophic condition to which they were reduced.

The young man, though with the best of good will, was utterly unable
to conquer the tendency to halt in his gait, and so the muscles
remained under-exercised and were used at a mechanical disadvantage,
with the usual painful result. He went to at least two prominent
orthopedic surgeons, who assured him that all he needed was confidence
in himself to walk straight, and that then the normal condition of the
muscles and absence of pain would result. But their directions were
absolutely without result. He went through the hands of masseurs, of
osteopaths, of rubbing quacks of all kinds, and suffered at least two
attacks of artificial eczema as a consequence of the use of turpentine
liniments, but he remained after it all in what he considered to be an
intensely miserable condition. These cases are practically always
cured by definite exercise of the muscles of the affected limb so as
to bring them back to their normal tone. It requires special attention
for this purpose, however, and the patient's mind must be brought to
understand that at first the unaccustomed use of muscles will cause
discomfort, but that this will disappear after a time. These patients
are persuaded that they must be "cured" to get well.

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