The art of treating the knee has advanced so rapidly in the past 15 years that orthopedists are hard pressed to keep up with the variety of injuries and instabilities they are learning to diagnose and define. Dr. Kerlan recently sent a memo to a nurse listing new classifications developed by Dr. Jack Hughston and Dr. James Andrews regarding eight basic forms of knee instability. The eight were: straight medial, straight lateral, straight posterior, straight anterior, anteromedial rotary, anterolateral rotary, posterolateral rotary and combined rotary instability.
Dr. Donald Slocum of Eugene, Ore., one of the top knee specialists in the U.S., says, "I don't think there are actually so many more knee injuries per player than there were before. I think what we have now is better diagnosis. We are recognizing new types of conditions all of the time as a result of that. And, of course, the types vary greatly with each sport. There is a different type of injury when the foot is planted on the ground as it receives a blow than there is when the knee is injured in the air—as with a skier, for example. There are many more types of knee injury now than before simply because more people are participating in so many different sports. Many types of injuries are becoming more common, but 15 years ago we didn't recognize them at all."
Knee injuries, as Dr. Slocum indicated, can come from multiple sources. Blows to the kneecap after constant pressure (such as one endures while kneeling to clean floors, the celebrated "housemaid's knee") can cause inflammation, tendinitis and dislocation. Countless mini-traumas are produced in the knee joints of long-distance runners, hurdlers, cyclists, cross-country skiers, even hikers—and each can eventually result in debilitating harm, such as a frayed patella tendon or damaged cartilage. Obviously, the thunderous jolt of a 250-pound body hurtling against the side of a locked knee can rip the tendons from the bone. Or a misstep on a tennis court—or while shagging a fungo, as happened to the Tigers' Mark Fidrych—can tear cartilage, strain a ligament, pinch the synovial tissue.
Dr. Hughston, who practices in Columbus, Ga. and is another of the nation's leading knee surgeons, says, "Most knee injuries are caused by pure accident. A boy runs off the field and steps on a teammate's foot and tears all the ligaments on the outside of his knee. Basketball players come down wrong on their feet. Pole-vaulters, tennis players and water skiers have a lot of knee problems. Most knee problems are caused by non-contact sports."
Yet to generalize at all on the basic causes of knee injuries may be folly. Here, briefly, are some theories from Dr. Nicholas, Namath's doctor, who founded the Institute of Sports Medicine and Athletic Trauma and is chairman of the Research and Education Committee of the American Orthopedic Society for Sports Medicine. Dr. Nicholas feels there may be too much stress put on the knee as a single isolated joint. He says, "You can't separate the joints one from another. They're all in a linkage system. To work on the knee you have to have a total conception of the body. There are 400 muscles, 600 ligaments. We may be getting too fragmented in our views. I'm strongly for the Knee Society, but we must keep in mind all the linkages."
Besides the myriad effects that an out-of-line hip or an inturned ankle can have on a knee, Dr. Nicholas points out that no two people are constructed exactly alike, no two knees react identically. "There is no average man," he says. "We are all slightly dissimilar to each other. Everyone has different kinds of stress on every joint. What works for one man—a preventive brace or special taping to protect a knee—won't work for another. Age makes a difference, too; as you get older you get tighter. No, there is no average man, and this makes preventive medicine tough."
Dr. Nicholas has come to believe that there is a relationship between serious knee injuries and a person's being loose-jointed or tight-jointed. In general he has discovered that people who are loose have injuries that differ markedly from those who are tight. The tight-jointed suffer more ruptured tendons, spinal-disc troubles and articular lesions inside the knee. They pull muscles more often, and tend to have more serious knee injuries. Loose-jointed people are more prone to dislocation of joints. Women, generally, are more loose-jointed than men, and have many more dislocated patellas than men.
One of the earliest practitioners of sports medicine as a specialized pursuit was Dr. Daniel H. Levinthal, now 82, a perky old fellow who recently retired after 58 years as an orthopedist. For 21 of those years he was an official team surgeon for the Chicago Bears. Dr. Dan, as he was called, estimates that he has operated on some 6,000 knees, many of them belonging to such athletic heroes of the past as Bill Osmanski ("That was a real lesson in anatomy, that knee") and Kenny Washington ("His knee was full of little marbles of cartilage"). "The injuries were a bit different in the old days," says Dr. Levinthal. "There was no artificial turf, which has come to be a serious problem. And the helmet was just a little leather thing, not a lethal weapon for spearing like it is now when it can crack a kneecap. Players are taught to hit harder now. In football there is a killer spirit that causes severe injuries of all kinds, especially to the knee. Of course, techniques for diagnosis were limited in the old days. We had the X ray, but you can't see anything but bone—cartilage and muscle do not show. And we had external examinations—the push-pull test for cruciate ligaments, rotation for the medial meniscus, the spring reflex to see if the knee straightens or stays bent. There were many routines for these tests. But the best, of course, was an incision. I could usually make a two-to-three-inch incision and see everything I could want to know about a knee."
An arthrotomy (opening the joint surgically) is still considered an excellent way to diagnose an injury, but it is painful and disabling, and diagnostic techniques have progressed beyond it, especially in the last 10 years or so. One well-tested method is the arthrogram, a form of X-ray procedure in which a special liquid dye is injected with air into the knee. Viewed through the X ray, the dye forms a pattern on the soft-tissue structures so that a ligament or cartilage tear can be seen clearly where the dye penetrates. The procedure is relatively painless and takes no more than 45 minutes.
Newer yet is the use of arthroscopy. This technique involves a tiny one-suture incision, through which a sort of tubular telescope is inserted directly into the inner knee for immediate viewing. With certain new optical equipment that produces a light source, the specific abnormalities of the knee can be directly observed by the doctor, and photographed or projected on a television screen. The use of arthroscopy usually involves a bit of complication and inconvenience, but more and more outpatient clinics are now set up to handle it. Even though general anesthesia is required, new techniques have shortened the procedure to a matter of hours.