FAQ

The cruciate ligament cannot be sewn back together. When it is torn in the middle, the blood supply to the cruciate ligament is cut off, which prevents healing. In about 20-30% of cases, however, the cruciate ligament tears at the very top, where it attaches to the thigh bone. If the entire end section is preserved, the cruciate ligament can be re-anchored at its attachment point - for example, with special dowel pins. This process is called reinsertion. It is important that the surgeon also makes a few small holes in front of, above, and behind the cruciate ligament, which stimulates healing as the stem cells are released from the bone.

If the cruciate ligament is torn in the middle, unfortunately it must be replaced. For this purpose, the patient’s own tendons (e.g., from the inner thigh) are used to create a new cruciate ligament. The best and gentlest way to perform this surgery is by using an all-inside technique.

CG: No. The ideal time is within 48 hours - but in cases when the knee is not exceptionally swollen or overheated, it is safe to operate 7-10 days after the ligament tear. Cold compresses, and possibly anti-inflammatory medication, are simple methods that can usually extend the surgical window.

The cruciate ligament does not always require surgery. Physiotherapy can often be sufficient for people who mainly cycle, swim, or don’t engage in any sports at all. If the knee joint does become unstable at some point (which happens in about 10% of cases), it is still possible to operate later. However, the situation is different with ball players, runners, and hikers. Many are able to stabilize the knee for a long period of time through their excellent musculature, and rarely or never experience instability - but all major studies show that athletes who play stop-and-go sports (e.g., ball sports), or who run or hike, have a significantly higher rate of early-onset arthritis if they choose not to have surgery. And it’s a shame, of course, to see a 40-year-old who needs a new knee joint because they didn’t have surgery for the torn cruciate ligament when they were young.

It depends on exactly how the meniscus is torn. Horizontal tears do not need surgery. Flap or radial tears should always be surgically repaired (which can be done with minimal invasion using arthroscopic keyhole surgery), as these kinds of tears can lead to cartilage damage and osteoarthritis if left untreated.

The cause of such complaints is often cartilage damage behind the kneecap, which is definitely something that should be looked into. And since only very severe cartilage damage can be diagnosed by X-ray, a 3-Tesla MRI should be used for assessment. This specialized kind of MRI makes even minor cartilage damage clearly visible. Mild cartilage damage can be effectively treated using a combination of physical therapy and cartilage medication, available as powders and tablets. Different forms of therapy are available to treat more severe cartilage damage, ranging from autologous blood transfusions to stem cell therapy to surgery. This is best decided on a case by case basis.

Iloprost is a prostaglandin medication that dilates blood vessels to stimulate blood flow. It is used to treat bone marrow lesions, also known as bone marrow edema. It can be particularly useful if the lesions are caused by Ahlback’s disease, a bone circulatory disorder that can lead to necrosis and destruction of the bone.

This is a cystic protrusion (like a small sac) of the joint capsule that pushes behind the knee joint into the hollow of the knee. The Baker’s cyst, also called a popliteal cyst, takes its name from English surgeon M. W. Baker, who first described it.

Baker’s cysts mostly arise as the result of chronic meniscus or cartilage damage, but can also occur in conjunction with chronic rheumatic knee disease.

The cysts usually occur in the hollow of the knee, which is where connective tissue is at its weakest.

As with all joints, the knee joint is covered by a thin, smooth layer of skin. This so-called synovial membrane produces articular fluid, which prevents friction in the joint and supplies the joint cartilage with nutrients. During embryonic development, the synovial membrane forms a barrier that divides the knee joint into two separate areas. (This is a holdover from the time when life emerged from the oceans and began moving on all fours. Horses, for example, still have two-part knee joints). Normally, this membrane diminishes entirely by the end of a child’s development, thus allowing for greater freedom of movement in the knee. However, in about 50–70% of adults, a small fold of tissue—called a plica—remains. This is usually located behind, above, or inside (medial) the kneecap.

Many people who have a plica have no problems at all, however, if the plica is more prominent, it can become irritated. Above all, overstraining of the knee joint can lead to plica irritation and thus to plica syndrome. Demanding activities in which the knee is repeatedly flexed and then extended again (such as running, cycling, and exercising on "steppers") are the most frequent causes. The plica itself, as well as the tissue around it, swells and becomes painful. The thickening then rubs on the cartilage inside the knee joint and can damage the joint cartilage or cause joint inflammation (arthritis) if exertion is continued.

The most common symptoms of plica syndrome are:

• Pain on exertion, mostly on the medial or posterior side of the patella
• "Creaking" or "popping" of the joint in a specific position while flexing it
• A "blocking" sensation during extension movements
• Stiffness in the joint after sitting for long periods
• In some cases, the thickened plica can also be felt under the skin, or swelling of the entire knee joint occurs.

Treatment:
Non-surgical therapy and treatment of the inflammatory irritation can be carried out in a first step. Rest is crucial here, in combination with treatment with anti-inflammatory medication. Cooling with ice is also helpful and can alleviate pain and swelling. The problem with plica syndrome in athletic patients, however, is that symptoms often do not improve, as inflammation has altered and hardened the edge of the plica, causing it to continue rubbing on the cartilage and destroying it. An operation (arthroscopy) should therefore be considered early on for athletic patients. The operation removes the plica and symptoms generally improve after a very short time—unless significant cartilage damage has already occurred. It should be made clear to the patient prior to operation that they may still have pain after the operation (due to cartilage damage).

If one looks at the bone canal (subacromial space) through which the rotator cuff runs, one can well imagine that stress could cause tendon damage. Like a climbing rope that begins to fray when pulled over a sharp edge, our tendons can also suffer minor injuries as part of normal movement. This is usually the case when the acromion has a steeper downwards angle, something that is genetically determined, or when degeneration has caused the acromion to narrow the subacromial space.

Our bodies try to heal these damaged fibers (for more, see: healing phases), which is typically associated with swelling and pain during phase one, the inflammation phase. This swelling causes the already narrow bony channel to become even tighter. The consequence of this is a kind of pinching of the soft muscle tissue (impingement), which causes pain when rotating the arm in and out, when lifting the arm, and particularly when lying on the affected shoulder at night. A shoulder impingement is sometimes also called Impingement Syndrome. Painful inflammation of the shoulder bursa is a common complaint associated with the syndrome. In most cases, such symptoms can be effectively treated with anti-inflammatory drugs and physical therapy. In some chronic cases, the bursa can become calcified (Bursitis calcarea), which can lead to persistent pain. This generally responds very well to shock wave therapy (ESWT) in conjunction with physical therapy. In unresponsive situations, an analgesic infusion and a small dose of cortisone can often be helpful (however, this should not be done more than 2-3 times). If none of these therapeutic measures provide healing or relief (or if the acromion is severely restricted), Dr. Gäbler recommends arthroscopic surgery to mill the acromion, which creates space and clears out any calcium deposits.

A dislocated shoulder should generally be looked at using an MRI arthrogram - i.e., an MRI conducted after injecting the joint with a solution. The anterior joint lip is often torn off in a shoulder dislocation, which means a high risk of the shoulder dislocating again (often with only minimal movement). However, in addition to often intense pain, any dislocation results in cartilage damage and thus osteoarthritis. Therefore, it is important to rule out this kind of injury (and of course any accompanying injury).

If an MRI shows that the labrum was torn off during dislocation, it should be surgically reattached especially if the patient is young and athletic. This can almost always be done arthroscopically, with minimal invasiveness.

Older and less physically active patients can be treated with more conservative methods (non-surgically), such as intensive physical therapy with special attention to the centering of the joint.

A Tossy III injury is a complete dislocation of the AC joint (acromioclavicular joint) with all stabilizing ligaments torn. This injury requires surgical intervention.

With this kind of AC joint dislocation, all of the anchoring ligaments to hold the collarbone in the correct position are torn. Dr. Gäbler does recommends surgery for athletic patients in cases like this. The operation sews the torn ligaments back together, and the collarbone is anchored into the underlying bone with special sutures that function similarly to a pulley (AS Tight Rope System). This allows recovering patients to shorten the phase of immobilization and start training again very quickly.

Inside the shoulder joint is a muscle group consisting of four muscles - the subscapularis, supraspinatus, infraspinatus, and teres minor - which envelop the head of the humerus from above like a cap. These muscles not only stabilize the shoulder joint, they also lift and turn the arm for rotational movement. Together, the four muscles are called the “rotator cuff”. An acute injury can cause the rotator cuff to tear, also called a rotator cuff lesion. Much more common, however, is the increasing wear and tear caused by impingement syndrome. This affects the supraspinatus tendon (the tendon of the supraspinatus muscle) most frequently.

With rotator cuff injuries, patients typically experience pain when lifting the arm, and often also a significant loss of strength. In some cases, it is no longer possible to even lift the arm.

In younger patients, rotator cuff injuries should be treated surgically. In most cases, the tear can be sutured using minimally invasive arthroscopy. This type of surgery leaves only three to four scars a few millimeters in size. For some larger or older injuries, it is not possible to use this method, and a skin incision about three centimeters in length may be required. Patients should be aware that, despite the operation, pain will usually persist for another 8-12 weeks - and intensive postoperative physical therapy is also required.

In older patients, a 3-to-6-month course of physical therapy can be tried first. However, since today’s surgical methods generally deliver very good results, an operation should not be postponed when patients complain of persistent pain and aggravating movement restrictions despite physiotherapy.

An arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure in which a narrow tube (4 mm diameter) is inserted into the joint being examined.

The images from inside the joint are transmitted via the endoscope to a video camera and one or more monitors. This enables the surgeon, and sometimes also the patient, to view the operation directly on the screen. For joint irrigation, a small cannula is usually inserted into the knee or other joint being operated on. Other instruments can be inserted through an additional small opening. The procedure can take between 20 and 60 minutes (longer for cruciate ligament operations) and is performed under general or regional anesthesia (e.g., an epidural).

Arthroscopy is used with particular frequency to operate on knee and shoulder joints. However, as surgical experience grows, the technique is increasingly being used for smaller and tighter joints such as the hip, hand, ankle, finger, elbow, and even the temporomandibular joint (jaw).

Also referred to as extracorporeal shockwave therapy (ESWT), this method uses high-energy acoustic waves to target and treat tendon attachment issues and muscle and bone conditions, and is largely free of complications. Shockwave therapy uses sound pulses focused deep within the body at the root cause of the pain, where they are most effective.

ESWT stimulates cell metabolism by activating mitochondria and releasing growth factors that accelerate the healing process of painful conditions such as tendon damage.

The sound waves also cause the formation of new blood vessels (angiogenesis and vasculogenesis), which improves circulation and stimulates the body’s self-healing mechanisms, making it possible for damaged or degenerated tissue to regenerate and heal.

It is also thought that shock wave therapy can cause stem cells to migrate and “come home”.

In the case of calcium deposits, such as calcific tendonitis of the shoulder, it is possible to directly shatter the deposit. This causes it to break down into small parts that are easily metabolized by the body.

ESWT also has a direct impact on pain transmission: First, the cell walls of the pain receptors are affected, causing them to transmit fewer negative impulses. Second, ESWT causes sensory overload in affected tissues and nerves, reducing their ability to transmit pain. In particular, chronic pain can be alleviated in the long term using this method.

Using ESWT, extremely rapid and sustainable improvements can be achieved without radiation.

• All types of tendon inflammation
• All types of tendonitis (non-inflammatory painful degeneration of the tendons), i.e., the Achilles tendon
• Tennis elbow / golf elbow
• Trochanteric pain syndrome (hip)
• Tendinitis calcarea (calcification in the tendon anchor area of the shoulder) and frozen shoulder
Sehnenansatzbereich der Schulter) und frozen shoulder
• Plantar fasciitis / heel spurs
• Fascia therapy
• Old cicatrized muscle injuries
• Fresh muscle injuries (low intensity and focused)
• Skeletal muscle pain
• Patellar tip syndrome and Morbus Schlatter disease (MOB)
• OCD in adults (degeneration of the cartilage bone area, usually in the knee or ankle joint)
• Pseudarthrosis in small bones
• Shin splints
• Tension of the neck and back muscles, persistent tension of the large muscles (upper arm, forearm, pelvic region, thigh, lower leg)

First, your physician will discuss the cause of your condition with you and explain why shockwave therapy would be effective in your situation. Possible complications such as superficial bruising, swelling, etc. are also discussed, and a consent form must be signed.

In most cases, three (in rare cases up to five) shockwave treatments are necessary. During treatment, a topical gel is first applied to the area to allow the shockwaves to penetrate into the body and target the problem area with no energy loss. The treatment itself takes five to ten minutes, during which time the doctor will explain each step of the process.

ESWT has a very high success rate when combined with an accurate diagnosis. However, no therapy has a 100% guarantee of success, and the degree of effectiveness also depends on the severity and prior duration of symptoms.

A heel spur is a thorn-like bone development on the underside of the heel at the base of the highly strained aponeurosis at the sole of the foot (the plantar fascia). The plantar fascia is a thick connective tissue that supports the arch of the foot to bear both left and transverse loads. When it becomes inflamed due to ongoing overexertion, the typical symptom is stabbing pain on the inside and/or underside of the heel, more intense in the morning and when just getting started.

The heel spur symptoms do not always indicate true ossificationv - instead, the pain is often caused by chronic inflammation that also includes the bursa of the heel bone.

A calcaneal spur, visible by X-ray, only occurs in about 10% of the population. Most people, however, experience no symptoms. The trigger for the symptoms of heel spurs is inflammation of the plantar aponeurosis (plantar fasciitis). This is caused by prolonged overstressing of the foot and tendons due to excessive pressure and tension on the aponeurosis at the sole of the foot beneath the heel bone. Repeated micro-tears of the tendon and chronic inflammation of the surrounding tissue occur at these overstressed areas, causing calcium deposits to develop. (As with a bone fracture, the body deposits calcium to heal the tears in the tendon and provide stability.) And just like that: a bone spur.

This explanation is supported by the fact that this type of heel pain is found in overweight individuals as well as in very active people and professional athletes. Patients with flat or splayed feet or high arches have a greater tendency to experience heel pain.