Dolor de rodilla

117

El dolor de rodilla es un problema, algunos autores lo han considerado como una enfermedad articular frecuente y otros como un problema de mecánica articular; pero lo que sí es cierto, es que es una de las causas de mayor consulta tanto al ortopedista como al reumatólogo.

El dolor de rodilla es un síntoma de múltiples causas que pueden ser responsables de la molestia.

Cuando un médico al que consultamos de pronto nos dice: “No te preocupes tu dolor de rodilla es por una lesión del menisco” Es cuando tenemos que dudar un poco del diagnóstico (un dolor de rodilla puede ser debido a muchas causas) pues los meniscos no duelen, no tienen nervios que transmitan dolor.

Artrosis de rodilla.

Artrosis significa proceso degenerativo (totalmente diferente del concepto artritis) y causa de dolor y rigidez de rodilla en personas de más de 50 años.

Casi a diario hay rigidez articular por la mañana de 20 a 30 minutos, los pacientes se quejan de que oyen crujidos, tronidos y chasquidos, produce poca inflamación y dolor aumenta al caminar y cede en reposo.

En la artrosis se produce una disminución del número de células del cartílago[1], por diversos mecanismos. La incidencia es variable, pero desde los 45 hasta los 65 años, el 20% de las mujeres y el 15% de los varones la desarrollan.

 

Genu-varo y genu-valgo. Son deformidades del ángulo normal de la rodilla, el varo da lugar a rodillas arqueadas, o rodillas en “O”, como se conocen, o bien con rodillas en forma de “X” y que se denomina genu-valgo.

En el genu varo o rodilla vara, existe una forma arqueada de las piernas sobre todo cuando vemos al paciente en posición de pie, es decir, la alineación de las extremidades inferiores nos muestra que los tobillos se tocan y las rodillas están separadas, de uno a dos centímetros hasta cerca de 10 a 12cms.

En cambio en la rodilla valga o genu valgo, las rodillas tienen la forma en “X” cuando el paciente está de pie, la alineación de las extremidades inferiores muestra que las rodillas se tocan y los tobillos están separados, esta separación puede ser de uno a dos centímetros hasta cerca de 12 centímetros (lo ortopédicamente considerado serían entre 6-8 centímetros).

La mayoría de veces la rodilla vara y la rodilla valga se resuelven de forma espontánea, entre los seis y ocho años, pero cuando estas deformidades no desaparecen o son más acentuadas hay que sospechar que pueda tratarse de una forma progresiva, que puede empeorar y con el tiempo traducirse en enfermedad de Blount (tibia vara)[2], diferentes tipos de raquitismo, afecciones óseas generalizadas (displasias óseas), secuelas de traumatismos o infecciones, por dar algunos ejemplos.

Durante la exploración de los miembros inferiores medimos el ángulo entre el muslo y la pierna (ángulo femorotibial) y la distancia entre las rodillas (en las formas varas) o la distancia entre los tobillos (en las formas valgas).

En algunos casos la deformidad puede ser tan acentuada que el ortopedista pudiera recomendar algún tipo de tratamiento, férulas, ejercicios o cirugía para corregir la deformidad. El diagnóstico se realiza por la exploración adecuada que realiza el médico, historia clínica detallada y por las radiografías específicas ordenadas por el especialista.

El diagnóstico adecuado del dolor de rodilla (gonalgia) por un médico es la mejor forma de evitar sorpresas desagradables y secuelas irreparables en ocasiones. El tratamiento será distinto en cada caso y dependerá de la causa de la dolencia. El cuidado médico debe ser prioridad cuando ocurren las primeras manifestaciones de dolor de rodillas.

 

Preguntas y respuestas en padecimientos de rodilla.

 

1.- Tengo 34 años y siempre que flexiono las rodillas me crujen tremendamente, pero no tengo dolor de rodillas. ¿A qué se debe esto?

Los pequeños resaltes, tronidos, crepitaciones o crujidos articulares que no se acompañan de dolor, incapacidad o hinchazón articular son hasta cierto punto naturales. En ocasiones pueden ser pequeñas pérdidas de adherencia momentánea de las superficies articulares, otras veces se deben a lesiones antiguas y que provocaron cicatrices (tejido fibroso), que cuando rozan entre sí provocan estos sonidos. No hay que preocuparse demasiado, y quizá lo más importante, es que no necesitan tratamiento alguno.

2.- Mi casa es de dos pisos, y tengo que subir y bajar escaleras todos los días ¿Esto puede ser perjudicial a la larga para mis rodillas?

Para personas que ya tienen dolor de rodilla y sobrepeso (u obesidad franca), las escaleras pueden ser un problema importante. En el momento en que hay que elevarse y dar el paso hacia arriba quizá el dolor o molestia no sean tan importantes; pero, al descender, la rótula tiene que actuar de freno similar al de una zapata de un coche para mantener la posición del cuerpo. Esto aumenta de manera importante la presión y la sobrecarga de la articulación y produce dolor en aquellos que tienen ya lesión del cartílago, como en la artrosis (proceso degenerativo) o, después de traumatismos. Las recomendaciones serían: acudir a su médico lo más pronto posible para que diagnostique el problema, apoyarse en el barandal, verificar el peso corporal, y la toma de algún medicamento antinflamatorio; recomendado por su médico y en lo posible evitar las escaleras, salvo que viva en un tercer piso, y ahí sí, ni que hablar.

3.- Tengo las rótulas desplazadas hacia afuera y a veces tengo dolores, sobre todo al bajar escaleras y rampas, e imposibilidad total a ponerme de rodillas o en cuclillas. Tengo 50 años, estoy sobrepasada de peso, pero no obesa. ¿Me gustaría saber si esta dolencia puede aumentar?

[ File # csp7475882, License # 1772593 ] Licensed through http://www.canstockphoto.com in accordance with the End User License Agreement (http://www.canstockphoto.com/legal.php) (c) Can Stock Photo Inc. / EraxionEl dolor de rótulas es muy frecuente y, como hemos dicho, a veces viene causado por una posición incorrecta de la rótula que viene determinada congénitamente. Ya hemos dicho que las escaleras, rampas y declives obligan a un trabajo añadido que aumenta el dolor. La posición de cuclillas, no debería realizarse, y menos en un paciente con dolor rotuliano. Otro factor que frecuentemente ocurre sobre todo en mujeres, es el uso constante de pantalones, que además de permitirles mejor movilidad, les provocan una insuficiencia muscular de los aductores, músculos que se encuentran en la parte interna del muslo.

La función principal de los músculos aductores de la cadera,  es la aducción de las articulaciones de las caderas, es decir, acercan los muslos hacia la línea media del cuerpo. Esta acción aunque parezca “natural” no la realizan las mujeres hoy en día, pues no tienen que cerrar sus muslos como lo hacían nuestras mamás o abuelas que usaban vestidos o faldas; al presentarse esta deficiencia muscular de aductores, puede desplazar a todo el cuádriceps junto con el tendón rotuliano llevando a la rótula hacia fuera y arriba, lo que provoca mayor problema de dolor, molestia y crepitación rotuliana.

Los aductores contribuyen a la rotación externa (pectíneo, aductor corto y el aductor mayor), la rotación hacia adentro (inserción tendinosa del aductor), flexión (todos) y la extensión (la inserción tendinosa del aductor).

Aparte de estas acciones básicas de movimiento, el grupo aductor tiene gran importancia en nuestra estabilidad y equilibrio. Al caminar, estos músculos funcionan para mantener el miembro pélvico en posición y evitar el desplazamiento lateral del mismo y mantenerlo recto.

En los hombres esto no es mucho problema, el ángulo Q es el formado por una línea que va desde la Espina Ilíaca Antero Superior (EIAS) (el “huesito de la risa” para entenderlo), al centro de la rótula (línea Verde) y la línea que va desde el centro de la rótula hasta la tuberosidad anterior de la tibia (Línea Roja) y es utilizado para medir el alineamiento de las rodillas. Las mujeres al tener más amplitud en su pelvis, hacen que el ángulo aumente y al no tener suficiente fuerza en los aductores, hace que se desplace el cuádriceps hacia afuera.

El tratamiento siempre se inicia sin recurrir a la cirugía (reducción de peso, fisioterapia, medicamentos, protectores del cartílago). El fortalecimiento muscular de los aductores, debe ser primordial, hay ejercicios específicos para esto; sin embargo, si el dolor progresa y la incapacidad articular es mayor habrá que pensar en la cirugía, que pudiera corregir la alineación rotuliana.

4.- Desde hace meses cuando voy caminando tengo dolor en ambas rodillas; pero últimamente me resulta casi imposible hincarme por la sensación de presión y dolor, y cuando lo hago es casi imposible levantarme, por lo que tengo que apoyarme en algo o que alguien me ayude. Tengo 52 años y me siento de 80.

Hemos comentado, que todas las posiciones que obliguen a la flexión forzada de rodillas, comprimen el cartílago de la rótula sobre el cartílago de los cóndilos femorales, esto, comprime parte de la membrana sinovial, que tiene nervios tan delgados como un cabello que causan el dolor. El diagnóstico, deberá realizarse en el consultorio, con la exploración clínica completa, radiografías específicas. Y sobre todo iniciar el tratamiento con la prevención de las actividades perjudiciales, reducción del peso corporal, esto es básico y más si tiene la cadera ancha, iniciar la fisioterapia y fortalecimiento de masas musculares de cuádriceps, flexores de rodilla, aductores y gemelos, además de medicamentos condroprotectores y en caso necesario antiinflamatorios no esteroideos (aine) estos indicados por su médico.

5.- Me han dicho que tengo un problema conocido como “rodillas de corredor”, pero yo ni siquiera corro. ¿Qué es lo que tengo entonces?

La rodilla del corredor es una condición que se empezó a ver en personas que corrían, a veces sin debidos cuidados, y se caracterizaba por dolor, crepitación de las mismas y sensación de cansancio; y se presentaba seis veces más en mujeres que hombres. Al estudiar esto, se vio que las mujeres al tener su cadera más ancha, sus muslos y piernas se desvían oblicuamente hacia adentro lo que crea una presión muy especial sobre las rótulas y cóndilos laterales de los fémures (hacia fuera).

Hay que considerar que el fémur de las mujeres tiende a ser “curvo” en relación al fémur de los hombres, y esto ocasiona que al dar el paso, en el momento de apoyo si la rótula se mueve, sobre todo hacia afuera, esto causará el dolor sobre los tendones externos y la Bursa (bolsa adiposa entre tendones para evitar que rocen entre sí). Por lo que no se necesita ser una atleta o corredora para sufrirla. La rodilla del corredor, también recibe el nombre de síndrome patelofemoral, y se presenta sobre todo en personas afectadas de artrosis (proceso degenerativo) o alteraciones en pies, como el pie plano o pie en pronación. Ejercicios musculares específicos o la utilización de unas plantillas correctoras, pueden aliviarle en forma extraordinaria.

Además, la alineación deficiente de rodillas sometidas a fuertes presiones y tensiones puede originar microlesiones en los cartílagos articulares y en el hueso, hasta el punto de llegar, con el paso de los años, a una artrosis importante (proceso degenerativo).

 

El dolor afecta a jóvenes y mayores

 El dolor de rodillas en personas mayores se debe, generalmente, a una artrosis (gonartrosis = gona: rodilla), pero también los jóvenes, incluso quienes no practican deporte alguno, están expuestos a molestias de diversa índole. Por ejemplo, el llamado síndrome femoro/patelar puede ser originado por muchas causas y es frecuente en adolescentes y mujeres jóvenes (menores de 35 años). Otros cuadros típicos que se aprecian en estas edades radican en lesiones del cartílago de la rótula o del fémur, como una condromalacia, osteocondritis disecante, puede haber inestabilidad de la rótula, colocación deficiente de la misma (alta, baja, desviación externa o interna, o pellizcamientos de la membrana sinovial; estas lesiones se traducen en un dolor alrededor de la rótula que se agrava con el ejercicio físico, particularmente al bajar escaleras y pendientes, al estar agachados o al permanecer largos periodos de tiempo con las rodillas flexionadas (en el cine, hincarse en la iglesia, trabajos especiales). Además, en ocasiones, puede parecer que la rodilla falla al correr o al caminar, que sufre una hinchazón (en la mayoría de los casos, la exploración física no evidencia derrame articular), o que presenta crujidos articulares.

La causa-efecto de las lesiones puede ser muy variada, de ahí que diagnosticar la afección lo antes posible resulta primordial para establecer el tratamiento más adecuado. Este puede incluir ejercicios isométricos para potenciar la musculatura (en especial, el cuádriceps, aductores y flexores de rodilla), estiramientos, aplicación de calor antes del ejercicio y de frío después de la actividad, utilizar rodilleras u ortesis de centraje rotuliano, plantillas para corregir varo o valgo de pies. En general, todo el conjunto de tratamientos garantiza la mejoría de la articulación, y en ocasiones en donde las molestias o el dolor sean persistentes, a pesar de todas las medidas conservadores se podría valorar una intervención quirúrgica, que podría consistir en una artroscopia.

 

Dr. José Luis Sánchez Mejía Ortopedia y Traumatología

pepeluigi58@yahoo.com.mx | www.drsanchezmejia.com.mx

[1] El término condropenia (poco cartílago) hace referencia al deterioro y adelgazamiento del cartílago articular y que es la causa de la artrosis. Hay múltiples factores en la génesis de este deterioro celular. En los próximos años, los tratamientos irán encaminados a sustituir el cartílago deteriorado por cartílago sano procedente de cultivos celulares. La ingeniería tisular y celular (tejidos y células madre), posiblemente serán en un futuro, una de las formas de tratamiento de la artrosis de rodilla.

[2] Es un trastorno del crecimiento de la tibia (hueso de la espinilla) provocando en la pierna un ángulo hacia adentro, pareciéndose a piernas arqueadas.

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