Malalignment of the Knee

Malalignment can be categorized into different types based on the direction of the malalignment.

• Genu Varum (Bowlegs): This malalignment occurs when the knees bow outward, creating a gap between them when the feet are together. In bowlegs, weight is primarily distributed on the knee’s inner (medial) part, increasing the risk of osteoarthritis in this area.
• Genu Valgum (Knock Knees): The knees angle inward in this condition, causing them to touch or come close together when the feet are apart. This misalignment places more pressure on the knee’s outer (lateral) side, leading to increased wear and tear in this region.
• Rotational Malalignment occurs when the femur (thigh bone) or tibia (shin bone) rotates abnormally. It may cause pain and instability and can contribute to patellar tracking issues or patellofemoral pain syndrome.
• Sagittal Plane Malalignment: This type affects the knee’s position in the sagittal plane (front-to-back), often leading to excessive knee flexion or extension. Commonly seen in conditions such as crouch gait, it can create difficulties in movement and may require specialized intervention.

The main causes of this condition can include:

• Genetics: Some people are born with bone structures that tend to be misaligned.
• Developmental Factors: Problems occurring while bones grow can lead to misalignment.
• Muscle Imbalances: Weak or tight muscles around the hips and knees can worsen alignment issues.
• Trauma or injury: Injury to the knee or surrounding structures, including fractures, ligament tears, and meniscus injuries, can result in malalignment.
• Arthritis: Osteoarthritis or rheumatoid arthritis can cause the wear and tear of joint cartilage, leading to malalignment over time.
• Obesity: Excessive body weight can place additional stress on the knee joints, potentially causing or exacerbating malalignment.

Individuals with knee malalignment may experience a range of symptoms, including:

• Physical activity or prolonged standing often worsens chronic pain and swelling around the knee joint.
• Knee stiffness and reduced range of motion make it difficult to fully straighten or bend the knee.
• A grinding or clicking sensation in the knee joint during movement.
• Patellar mal tracking (patellar instability) occurs when the kneecap (patella) does not move smoothly within its groove on the femur, leading to pain and, sometimes, instability.
• A feeling of the knee giving way or being unstable can make balance, walking, and other activities challenging.
• Changes in the way a person walks, often with a noticeable inward turning of the knees (knock-knees) and feet pointing inwards, create added stress on other joints.
• Misalignment in the knees can cause hip and ankle pain due to altered biomechanics.

Dr. Brian Waterman will review your medical history and inquire about your symptoms and what causes them. He will assess your leg alignment, range of motion, muscle strength, and gait (walking) analysis. He will order X-rays and may obtain MRI and CT scans to visualize the bone structures and determine the location and extent of the malalignment.

The treatment for knee malalignment depends on the underlying cause, the severity of the condition, and the patient’s overall health and activity level. Options include:

• Conservative management of miserable malalignment syndrome focuses on non-surgical approaches to relieve symptoms and improve function.
  • Pain relievers and anti-inflammatory medicines to manage symptoms and help patients maintain an active and comfortable lifestyle.
  • Physical therapy plays a crucial role, with exercises designed to strengthen the muscles around the knee (including the pelvis and core), enhance flexibility, and correct any abnormalities in gait.
  • Orthotics, such as custom-made shoe inserts or unloader braces, support proper alignment and reduce stress on the knee joint.
  • Lifestyle modifications like maintaining a healthy weight to reduce stress on the knee joint and activity modification to avoid those activities that worsen symptoms, such as high-impact sports.
• For more severe cases, surgery may be necessary to realign the bones and eliminate knee pain. Surgical procedures include:
  • Osteotomy is a procedure to cut and realign the bones to correct the deformity. This may involve the femur (thighbone), tibia (shin bone), or both. The four primary types of osteotomy include:
    • A tibial osteotomy involves cutting the tibia (shinbone) to correct alignment, typically to redistribute weight and relieve pressure on a damaged part of the knee. This procedure is commonly used for patients with knee osteoarthritis, which affects only one side of the knee. By changing the alignment, the knee joint can function more effectively, which helps alleviate pain and slow arthritis progression.
    • A distal femoral osteotomy involves making a controlled cut in the femur (thighbone) to correct valgus (knock-knee) deformities. This surgical approach redistributes weight away from the knee’s lateral (outer) compartment, easing pain and reducing stress on the joint.
    • A tibial tubercle osteotomy involves moving the tibial tubercle, where the patellar tendon attaches to the tibia, to address patellar maltracking or instability. Misalignment in this area can cause kneecap dislocations or contribute to patellofemoral pain syndrome.
    • A derotational osteotomy is performed to correct abnormal rotational alignment in the femur or tibia. Rotational deformities, congenital or resulting from trauma, can disrupt gait and cause knee pain due to improper joint mechanics.

• Arthroscopy is a minimally invasive surgery to repair any damage to the knee joint, such as damaged cartilage or meniscus tears.