Frasier Crane and Michael Caine? Get Your Knees Up!

Cockneys are a breed of Londoner, qualified as such by being born within the sound of the bells of St. Mary-le-Bow Church, whose curfew toll dates back a thousand years. 

In turn, cockney emanates from Chaucer in the 14th century, a cokenay, or pampered person. Cockneys are known for their cheeky humor, streetwise attitude and unique patois, a pattern of speech where a phrase, usually two somewhat-associated words, rhymes with the target word. Hence, “apples and pears” means “stairs,” and “skin and blister” refers to “sister.” To make this even more baffling, the dedicated cockney may use just one of the two words, “apples” or “skin” in the above examples, and because language is a living thing, new phrases appear with frequency. For instance, “pain,” the subject of this missive, can be described as a bit of “Michael” or a spot of “Frasier.” And you thought medicine was complicated?

The specific pain I am referring to is from the knee, a joint that copes with more impacts than a student pilot attempting brisk crosswind landings on an uneven grass strip. The knee is a hinge joint comprised of the femur, or thigh bone, and the tibia, or shin bone, as well as the patella, or kneecap, that lives within the tendon of the quadriceps femoris or “quads” muscles in front of the joint. The opposing surfaces of femur and tibia, and the back of the patella, are coated with hyaline cartilage, which facilitates smooth movement. Where femur and tibia meet, there are strong fibrous ligaments tying the bones together on the edges, and inside the joint there are two other ligaments that form a cross shape, the anterior and posterior cruciates, hence ACL and PCL, which you may have heard of. Additionally, within the joint there are two crescents of shock-absorbing fibrous cartilage called the menisci, and additional joint stability is provided by the muscles that cross the joint, allowing it to move back and forth. Finally, there are fluid-filled sacs above, below and in front of the patella, called the bursas.

Knee pain is extremely common and can be due to issues with any of these structures and induced by numerous causes. In addition to pain, other symptoms include reduced mobility, swelling, stiffness, locking, warmth to the touch and various noises such as crunching. Pilots do not like to hear noises emanating from aircraft undercarriage other than the reassuring clunk as it deploys; likewise, our knees are supposed to be silent! If pain commences directly after a fall or other trauma, mechanism of injury, location of pain, tenderness, impaired movements and other symptoms and signs will help define the damage. For instance, falling onto the knee can fracture the tibia or fibula (the outer shin bone) or patella; a high-velocity injury can shatter the femur. Alternatively, a twisting movement with the foot planted, producing sudden, severe pain on the inside joint edge, might suggest a tear or bruising of the ligaments on that side, the ACL or a meniscus tear. With the latter, the knee may lock, and one has to move the shin back and forth to be able to straighten the leg.

With increased age, repeated insults can lead to abrasion of the hyaline cartilage with resulting osteoarthritis. This tends to cause constant aching pain worse with movement and the aforementioned crunching sounds as well as pain on ambulation.

Sometimes one may notice swelling in front of the patella with redness, tenderness and a sense of fluid below the skin. This may be prepatellar bursitis, which is inflammation of the bursa and bears the politically incorrect name housemaid’s knee, is caused by excessive kneeling, perhaps while working on aircraft shock absorbers! Treatment is simple; anti-inflammatory medications, rest, ice and strengthening exercises often lead to rapid resolution.

Repetitive movements and athletic activity can lead to tendonitis, swelling of the part of a muscle that attaches to bone. This is not uncommon around the knee in skiers, runners or those deeming it wise to parachute from a perfectly good airplane. Cyclists, runners, and those addicted to striking golf balls with repetition can have swelling of the iliotibial band, a tendon spanning from the hip and attaching to the outer part of the knee; this responds well to rest and physiotherapy.

Waking with a sore and swollen knee and other joints may lead to a diagnosis of rheumatoid arthritis or one of the many other inflammatory joint conditions; these tend to be more common in women, but men are not immune.

Certain problems with metabolism such as gout can lead to joint pain; here, crystals of uric acid are deposited inside joints, acting as irritants. Should there be a penetrating injury, an infection can result inside the knee which can be extremely dangerous, even life-threatening if not attended to. If there is no good reason for persistent pain, other more sinister causes may be lurking such as tumors, most commonly from elsewhere in the body including lung and prostate.

Sometimes knee pain may lead to a diagnosis of a back problem; prolapsing discs between the spinal vertebrae can cause pain to be referred to the knee, so don’t be surprised if your doctor wants to examine an area of your body that is not the source of complaint! On occasion, lower back or hip pain on the other side changes our gait, inducing abnormal knee loading and pain.

As always, prevention is better than cure. Keeping weight down reduces stresses on joints and fat accumulating in muscles and other tissues which weakens them. Regular exercise to keep muscles strong helps protect joints from unnecessary forces, and always prepare for exercise with proper stretching. Using hiking poles for long walks helps distribute weight more evenly and proper footwear for the exercise in question is critical.

One should consider seeing the doctor if pain seems out of proportion to an injury or range of motion is impaired, or for an inability to bear weight, a noted deformity or swelling or a fever and red knee. After taking a history and doing a thorough examination, the doctor may order some blood tests, regular X-rays and an MRI.

Very often, problems can be resolved with rest, ice, compression and elevation (RICE), use of supportive braces or various physical therapy maneuvers, including special exercises, heat or ultrasound. Sometimes, injections of platelet rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and other substances are used to encourage healing, although these regenerative medicine techniques are still somewhat experimental.

If clinical findings and MRI suggest damaged tissues or loose bodies – pieces of cartilage, for instance – in the joint, a specialist orthopedic surgeon may recommend a diagnostic or therapeutic arthroscopy, where they look inside the joint with a small telescope, often under local anesthesia. At such time, one can remove loose bodies and repair damaged tissues. However, more extensive damage might require repairing ligaments with various grafts of either biological materials, such as a tendon from elsewhere in the body or from a donor, or synthetic materials. If arthritic damage to the knee is severe, a new joint of metal, plastic or ceramic material is implanted, usually with excellent results; many patients state that their only regret is how long they waited.

From an aviator’s perspective, if you have knee pain, regardless of cause, self-ground until able to freely and fully use your leg; an aching knee could impair safe operation of the aircraft. Depending on cause, there may be more complex aeromedical sequelae; for instance, after a knee replacement there is no specified grounding time, just when you are released for normal activities by the surgeon, and you feel well enough. One will need several documents at the next AME appointment, including the admission history and examination, operative report and discharge summary as well as a report from your surgeon detailing your symptoms, mobility, strength, current medications and prognosis.

In cockney culture, a “knees up” refers to a “Russell” (Russel Hearty = party) and particularly to an energetic “Jack” (Jack Palance = dance) and is epitomized by a song from the 1800s, “Knees Up Mother Brown.” Here’s hoping your “biscuits” (biscuits and cheese = knees) stay healthy, but if you have some Frasier or Michael, do me a “lemon” (lemon flavor = favor) and use your “loaf” (loaf of bread = head) and let the doctor have a “butchers” (butchers hook = look). Until next time, fly well, or in cockney, steak and kidney pie dingley dell!

You can send your questions and comments to Dr. Sackier via email: [email protected] and listen to his weekly podcasts at:

Jonathan Sackier

Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.
Topics: Pilot Health and Medical Certification, Pilot Health and Medical Certification

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