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

ener y 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

Troubles.



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.