Knee pain is a very common problem that can occur in people of all ages. It can be the result of an injury, such as a ruptured ligament or torn cartilage, or it can be caused by certain medical conditions including arthritis, gout, and infection. Some knee pain can be so severe that it may limit the range of movement of the knee and cause it to lock. There are various treatments for knee pain, which are dependent on the cause of the pain and its severity. For many people, knee pain that is the result of an injury can be treated by resting the leg, elevating it, and applying ice packs to the affected area. Prolonged problems caused by chronic conditions will often be treated by physiotherapy, exercise, or in severe cases, by surgery. The specialist who is best qualified to diagnose and treat knee problems is an orthopedic surgeon. This collection of interviews is designed to give patients a better understanding of their knee pain and its causes, therefore empowering them to make well-informed decisions about their treatment options.
Understanding Knee Pain
Knee pain has many causes, and understanding the anatomy of the knee may help guide the magnitude of a physician’s examination and influence a specific diagnosis. Your knee pain can be referred from other parts and regions of the leg. For instance, pain from the hip joint, particularly from osteonecrosis (death of bone) or osteoarthritis, may be felt in the groin or on the inside of the knee. Pain from the L4/L5 level of the spine can be referred to the medial lower leg. Another example is an injury to the knee which can cause inflammation and pain in the joint and lead to abnormal movement of the kneecap, causing wear and tear and degenerative pain. Knowing the precise location of your pain and how it started can help identify the exact cause of pain.
Your knee is a complex and important part of the body which helps everyday activities such as sitting, standing, and walking possible. Your knee is made up of the lower part of the thighbone, the upper end of the shinbone, and the kneecap. The center of the joint has a bulge on top of the shin bone. Your knee is made up of the top end of the thigh bone, shin bone, and the kneecap. The knee is supported by ligaments, some are attached to the bones and form the joint, while others are buried inside the joint. Cartilage is another structure which is like padding and helps ensure smoother movement. There are also small sacs of fluid called bursae which help reduce friction in the knee. Anything damaged could be a source of your knee pain.
Common Causes of Knee Pain
Osteoarthritis: This is the most common type of arthritis and is a degenerative joint disease, most often affecting middle-aged and elderly people. Younger people can also be affected. Osteoarthritis develops in the knee for many reasons and often has no clear cause. It is not simply a case of wear and tear, as there are people with old-looking x-rays of their knee joint who have no pain. The main symptom is pain, usually worsened by activity and relieved by rest, although in severe cases, the pain may be constant.
Overuse injury: Excessive repeated stress to the knee is a common cause of overuse injuries. In time, this can cause pain. A stress fracture can occur in the knee joint or the bone supporting the knee. Runner’s knee is due to the kneecap being repeatedly overstressed and is a common condition in people, often not just runners, who are very active. Iliotibial band syndrome is another overuse injury often seen in runners and cyclists. It occurs when the iliotibial band, the ligament that runs down the outside of the thigh from the hip to the shin, is tight or inflamed and rubs on the femur. This typically causes sharp or burning pain on the outer side of the knee.
Sudden injury: People often sprain, strain, or tear a ligament or tendon in the knee. These can cause pain and swelling. An injury to the front of the knee (anterior knee pain) may be caused by an acute patellar (kneecap) dislocation. This is a different injury than kneecap osteoarthritis, which develops more slowly over time. An injury may also cause a meniscal cartilage tear. This often happens during twisting or turning quickly when the foot is planted and the knee is bent. This is a common sports injury.
Knee pain can be caused by a sudden injury, an overuse injury, or by an underlying condition, such as arthritis.
Importance of Seeking Specialist Help
So while you have no trouble getting around, you’re more than likely still finding it difficult not to notice this niggling pain in your knee! Well, have you ever considered what it could be, or why it is that you’re affected by it? Knee pain is a common problem that can occur in the young and the old. It may be due to an injury, such as a ruptured ligament or torn cartilage. But medical conditions including infections, gout, and arthritis can also affect the knee. Some problems that build up over time, such as movement disorders and muscle imbalance, can be contributing factors to knee pain. Finally, there are some more serious conditions such as bone tumors and spine-related knee pain. Although less common, it is essential that they are not overlooked. With so many possibilities as to what can be the root of one’s knee pain, it’s crucial that you seek out specialist advice.
Expert Tips for Managing Knee Pain
It is quite clear that people respond differently to exercise. The effectiveness of an exercise program is best judged by its effect on symptoms and the progression or lack of progression of structural damage to the joint. Any increase in joint pain that persists for more than 2 hours after exercise is an indication that the intensity or duration of exercise is too high and it should be decreased. If the pain persists, then the exercise program should be altered or modified, and if pain still persists, the exercise should be discontinued and the situation should be reassessed by a knee pain specialist.
Range of passive motion exercises can be done to prevent joint contracture and to maintain or even improve joint motion. Strengthening exercises for the quadriceps are the key exercise of any exercise program for knee osteoarthritis. The quadriceps muscle is the primary protector of the knee joint. Studies show that progressive strengthening of the quadriceps is associated with less pain and with prevention of further cartilage loss in the knee joint. High-intensity isometric strengthening exercises can be done without stress to the joint and are very effective for people with significant joint pain. Aerobic exercise, particularly low-impact activities such as biking, swimming, and use of stationary aerobic exercise machines, can be effective for the improvement of general arthritic symptoms throughout the body. This is quite helpful for the arthritis sufferer who has systemic symptoms throughout the body. A program of regular aerobic exercise and/or participation in a specific exercise program can be an effective form of therapy for people with clinical depression, a common associated ailment for people with chronic medical conditions. Several studies have shown that aerobic exercise has a positive effect on physical function and pain in people suffering from knee osteoarthritis.
Inactivity can lead to more joint pain and the loss of joint movement, resulting in more inflammation and pain. Your doctor or physical therapist can work with you to develop an exercise program that will give you the most benefit with the least stress on your joint. It is critical that the individual pace the intensity of their exercise and the duration of the exercise to prevent increased joint pain and further damage to the joint. Some pain during exercise is expected, especially if the joint has been relatively inactive; however, there should be no pain in the joint during or after exercise. Measures to decrease inflammation and pain, such as ice application following exercise and use of nonsteroidal anti-inflammatory drugs, can be quite helpful.
When the knees started to hurt, the first reaction may be to cut back on movement and to rest. Yet this is generally not the right advice for those with osteoarthritis. Studies show that lack of exercise leads to decreased muscle strength and flexibility, further limiting joint movement and causing more pain.
Exercise and Physical Therapy
Exercise is an effective way to help manage pain and improve function with knee osteoarthritis. Several studies have confirmed the benefits of exercise for knee pain. Supervised exercise therapy has been shown to decrease pain and increase function in people with knee osteoarthritis. The benefit of exercise on knee pain is similar to that of taking NSAID medications. Many types of exercise have been shown to be effective for people with knee osteoarthritis. Strengthening the muscles around the knee is important because it offloads the knee joint. This is especially true for the quadriceps muscles. It has been shown that for every 1 lb of body weight lost, there is a 4 lb reduction in load exerted on the knee for each step taken. Weight loss can be achieved through calorie restriction or a combination of diet and exercise. Aerobic conditioning has benefits for the entire body and still can be done in ways that are osteoarthritis-friendly such as biking or swimming. Flexibility and range of motion exercise can help with stiffness and maintain normal joint function. This can include activities like yoga or tai chi which have been shown to help people with osteoarthritis maintain function and decrease pain. In general, any exercise is better than no exercise for people suffering from knee osteoarthritis. The key is finding an enjoyable activity that can be done regularly. All exercise should be done in moderation and progress slowly. Overdoing it can lead to increased knee pain and further joint damage. A physical therapist can be helpful in instructing the proper exercise methods and creating an exercise program tailored to specific patient needs.
Medications and Pain Relief
Pain medications are the simplest solution for those with chronic knee pain, and they focus on improving or maintaining a patient’s quality of life. Paracetamol, also known as acetaminophen, is recommended for the first-line oral analgesic. It is the safest option and acts on all pain types. However, it can take several weeks to determine if the drug will work. The potential presence of opiates such as codeine in some paracetamol brands presents a small issue when using the drug for long-term pain treatment. LLLT, also known as low-level laser therapy, is a newer form of pain medication which is now recommended by some clinicians and is advised for knee osteoarthritis knee pain and swelling. A meta-analysis published in The Lancet in March 2019 concluded that LLLT could have a moderate effect in improving pain and joint function without any adverse side effects but stated that more research was required in order to determine ideal treatment parameters and understand the best knee pain sufferers suited for this form of treatment.
As for TLC, it is useful in improving mental state and general wellbeing. It is associated with a slight risk of muscle and liver problems. NSAIDs and COX-2 inhibitors are preferred for a number of conditions such as inflammation, muscle injury, and osteoarthritis. However, they are not advised for people with heart conditions, hypertension, and kidney disease. Corticosteroid injections are most commonly used to reduce swelling and soreness in and around the joint. They are a short-term fix with results usually only lasting a few weeks to several months. The potential benefits and risks involved with knee pain sufferers using these injections were recently the topic of a PubMed article in April 2021. The researchers outlined that an increased rate of corticosteroid injections could lead to more severe knee osteoarthritis and a more inclined path to total knee replacement. Alternatively, the injections pose no risk of systemic side effects. The last option for most severe knee pain cases would be opioid and narcotic medication, and these are usually a last resort for knee pain physicians due to the risk of addiction, side effects, and limited evidence on pain and function improvement with opioid use for osteoarthritis and chronic pain.
Lifestyle Modifications
Moderating activity can help decrease strain on the knees. Utilizing a stick can help in changing the stacking from the legs to the arms, diminishing the weight on the knees. Supportive props can help redesign the handiness of a seriously impacted lower extremity. For example, using a knee support can help decrease the load on the joint, giving assistance and lightening torment. Utilizing shoe inserts can offer assistance to lower legs and knees by modifying foot arrangement. Unloading or motion control shoe inserts are a kind of shoe inserts that can help with ordering knee torment by altering the foot arrangement. Shoes can help in forming the timing of the knee and can thoroughly change the measure of weight that is applied over the joint during step. This, in turn, can be used to control the area of loading on a joint by changing the amount or kind of shoe worn.
Alternative Therapies
Similarly, the benefit of arthroscopy is very limited and is only likely to be of help for people with clearly defined mechanical symptoms such as a loose body in the knee.
High tibial osteotomy and knee arthroscopy are surgical procedures that are occasionally used as a last resort to try to delay the onset of knee replacement in younger, more active people with bad knee osteoarthritis. Osteotomy involves cutting and realigning the bones about the knee joint to shift the weight away from the damaged part of the knee. This would only be of help for people who have unicompartmental osteoarthritis, meaning the damage is only in one part of the knee. A recent study has shown that a specific type of tibial osteotomy called the opening wedge technique is better than high tibial arthroplasty and has a similar long-term cost efficacy to unicompartmental knee replacement. Osteotomy is a major operation with a long rehabilitation time but it may be helpful for the right group of people.
Massage can perhaps be beneficial, at least in the short term, in that it can reduce muscle tension around the knee. A recent systematic review has shown that prolotherapy can be helpful in the treatment of knee osteoarthritis. This is a therapy where a series of injections are given which are thought to stimulate a healing response in the injected tissues. The solution can be anything from dextrose to more controversial solutions like sodium morrhuate. The evidence for prolotherapy is growing but it still is limited and may not be accessible.
Alternative therapies are another very common way for people to try to manage knee pain. The evidence for these therapies, however, is very limited. A lot of the studies are of poor quality and have conflicting results. Acupuncture, for example, is popular but the trials done have been of very poor quality. There is some evidence to show that tai chi is beneficial for knee osteoarthritis, at least in the short term. A recent study has shown that a special blend of Chinese medicine called Du Huo Ji Sheng Tang was better than placebo for knee pain. This was a small trial though and more research would need to be done before this could become a recommended treatment.
Surgical Options for Knee Pain
For the right indications, arthroscopy may be able to relieve pain caused by a specific problem within the knee and may prevent further damage to the joint or slow the progress of arthritis. Examples of deformity that can be corrected are a torn meniscal cartilage or a loose fragment that is catching in the joint. Unfortunately, arthritic knees without a mechanical cause or knees with widespread arthritis do not do as well, and a “debriding” arthroscopy (cleaning up the knee) may only give short-term relief. This procedure is less likely to benefit patients with pain originating from the kneecap.
Arthroscopy is a surgical procedure in which a small telescope is inserted into the knee joint to look for the source of the problem. This is a day surgery procedure. If the problem can be corrected, special instruments will be inserted to carry out the repair. This may involve trimming torn cartilage, removing loose fragments of bone or cartilage, removing the lining of the joint which is producing inflammatory tissue (synovectomy), or releasing tight, contracted, or scarred joint capsule or ligaments.
In some cases, conservative treatments such as physiotherapy, medication, or injections are unable to relieve pain and the orthopaedic specialist may recommend one of the several surgical options. The type of surgery will depend on the diagnosis, the patient’s age, occupation, level of activity, general health, and the benefits and risks of the procedure. The main types of surgery are arthroscopy and knee replacement surgery.
Arthroscopy
Arthroscopy can often be used as a tool to both confirm the diagnosis and treat the condition itself. The name is derived from two Greek words—”arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint.” During arthroscopy, a small incision is made in the patient’s skin and then a pencil-sized instrument called an “arthroscope” is inserted. An arthroscope has a small lens and lighting system on the end of it that allows a lighted picture to be transmitted to a video monitor enabling the surgeon to see inside the joint. The video monitor is used so that the surgeon can see the inside of the knee through very small incisions. Additional small incisions may be made to insert surgical instruments. This is performed by a variety of techniques and is commonly done by “shaving” taking small amounts of tissue at a time, or “cutting and removing” the torn structure. Most repairs can be done in a minimally invasive manner provided they are able to be done with the arthroscope. With modern day advances, more complex procedures are being done in this manner. The goal is to correct the issue with as little damage to the surrounding healthy tissue as possible. Due to the minimally invasive nature of arthroscopy, it generally has a shorter healing and recovery period as compared to traditional open surgery.
Knee Replacement Surgery
After knee replacement surgery, you are usually standing and moving the knee on the same day and are able to go home after three to five days. You will have a six to 10-inch incision from the center of your knee. In general, knee movements are not restricted after surgery, unless there is a compelling reason to protect the knee from certain positions or excessive loads. Therefore, you can kneel, squat, and sit on the floor. The knee will be swollen for some time, usually for a week or two but sometimes for months, and you may have to continue taking some medication during this period. You can drive as soon as you are able to bend the knee sufficiently and as long as you are not taking strong medication that may affect your attention, e.g., narcotics. This is usually possible by four to six weeks after the operation. Full recovery from the surgery will take three to six months. However, you should be able to resume most normal activities six weeks after your operation, although you will need time to build up to them. High-impact activities are best avoided; these include jogging, vigorous swimming, and singles tennis. A contemporary design total knee is expected to last 10-15 years. This may be much longer in the older less active person and is often shorter in the younger more active person. If the joint wears out over time, a second operation may be necessary. This is usually a very good operation with a rapid recovery, the main difficulty being the decision to do it. A knee that has loosened because of bone loss is more difficult to solve and may involve a bone graft or a long stem revision. Similar principles to primary knee replacement would be followed.
The knee is divided into three compartments: medial, lateral, and patellofemoral. In total knee replacement, the damaged areas of the knee are resurfaced with metal and plastic. Usually, the procedure consists of replacing the joint surfaces in the femur and tibia, and if necessary, the patella. In a few cases, only one side of the knee is affected and can be a candidate for a unicompartmental knee replacement. Traditional total knee replacement is more common, and usually the most successful. The decision to perform a total knee replacement is based on the extent of damage in your knee, pain, and disability. A number of conditions can cause damage to the joint surfaces in the knee, and the most common cause is arthritis. Arthritis affects the knee joint by destroying the articular cartilage, the smooth gliding surface covering the ends of the femur and tibia. The absence of the articular cartilage can be very painful as bone rubs on bone. Also, when the cartilage is worn and only small remnants remain, the joint can become unstable and cause a loss of function. A knee replacement contemporary design surgical procedure recreates the normal mechanics of the knee.
Joint replacement surgery is considered only after other forms of treatment have failed to relieve the pain and stiffness of arthritis. The decision to have knee replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. Coming to a decision to have the surgery and preparing for it are important. An understanding of what surgery can do, and what it cannot do, is also important. This entire process is usually very involved for patients, and it is a considered decision that is made carefully.
Rehabilitation and Recovery
When rehabilitation is discussed in context with arthroscopic surgery on the knee, it is very important that the individual understands that the post-operative rehabilitation will vary depending on what the surgeon has done within the knee. The rehabilitation after a torn meniscus that has been trimmed is quite different from rehabilitation where a torn anterior cruciate ligament has been reconstructed. Despite this, there are a number of similarities in the rehabilitation protocols; hence, a broad overview of rehabilitation of an arthroscopy will be provided.
Rehabilitation and recovery timelines are as variable as the surgical procedures themselves. These will depend on the nature of the damage to the knee, the type of surgery performed, and the patient’s pre-operative level of function, as well as other factors such as commitment to rehabilitation, overall health, and adherence to the advice of the healthcare professional.
Preventive Measures for Knee Pain
Footwear is often an overlooked factor in knee pain prevention. The shoes we wear affect the way we walk, which means they can affect the alignment and stress on the knees. Certain shoes and types of footwear can place more stress on the knees. For example, shoes with worn-out soles or uneven heels can cause alignment issues that either cause or exacerbate knee pain. Typically, flat shoes are not recommended for people who suffer from knee pain, and some specific foot deformities or alignment issues may benefit from special shoes or shoe inserts called orthotics. It is best to consult with a podiatrist or an orthotist, who are trained specialists that can evaluate your feet and shoe needs.
When it comes to knee pain prevention, weight is important. Since every additional pound contributes to extra stress on your knee, maintaining a healthy weight is a key factor in preventing knee pain. Even a small weight loss can make a huge difference. For example, if you are overweight, losing as little as 5 percent of your body weight can help decrease stress on your knee. Furthermore, weight loss has numerous other health benefits, including reduced risk of chronic diseases such as heart disease and diabetes. This can be highly motivating, and many people find losing weight to be an achievable goal with the right support. A primary care physician or a nutritionist can help you set achievable goals and provide support to help you succeed in weight loss.
Maintaining Healthy Weight
To lose a few pounds, you need to take in fewer calories than your body needs. This is best achieved by reducing your daily intake by 500 calories. In addition, it is important to eat a variety of healthy foods and remain physically active, as calorie reduction alone will not ensure continued weight loss. Your goal should be to lose no more than a pound per week. While this may seem like slow progress, it is the healthiest way to lose weight and increases your chances at long-term success.
Understanding BMI. A BMI between 18.5 and 24.9 is considered healthy. If your BMI is 25 or higher, you weigh more than is healthy for someone of your height. Excess weight increases your risk of developing knee OA. In fact, for every pound of weight you gain, you add 4 pounds of pressure on your knees and as many as 8 pounds of pressure on your hips. This added pressure can cause damage to the joints and lead to arthritis in those areas. Weight also increases the risk of rheumatoid arthritis.
To maintain a healthy weight, find out what weight is healthy for you. One way to do this is to calculate your body mass index (BMI), a measure of body fat based on your height and weight. Find out what your BMI is, and learn the healthy range for men and women, online at the National Heart, Lung and Blood Institute’s (NHLBI’s) Aim for a Healthy Weight Website.
Proper Footwear and Orthotics
For those requiring more stability for flat feet, the use of a custom made orthotic in a sports shoe can often be beneficial.
In a recent study of people with osteoarthritis of the knee, walking barefoot increased joint loading in their knees. In comparison, walking with stability shoes reduced the load in their knees. Stability shoes are designed to provide increased support for the medial longitudinal arch. Although the availability in knee pain Singapore is limited, several shoe manufacturers have recently produced walking shoes with a ‘rocker’ sole, which has been shown to decrease knee joint stress. This is because the shoe design causes the pressure to be shifted more towards the toe and off the heel, essentially unloading the knee.
Your feet are the foundation of your body, and having proper support for them will assist in preventing knee problems. The cushioning and arch support in sports shoes can help absorb the pounding that running and jumping exercise puts on your knees. Our podiatrists remind us that the lifetime of a running shoe is 500 miles or about 6 months. As the cushioning properties deteriorate and the sole and upper are worn or broken, the shoe no longer provides the support that your foot and ankle requires.
Warm-up and Stretching Exercises
As the name implies, these exercises are aimed at warming up the lower limb muscles and stretching them to maintain good muscle and joint flexibility. A typical warm up should consist of at least 5 minutes of aerobic exercises such as walking or cycling. This is to elevate body temperature and increase blood flow to the muscles. After the warm up, warm down with some gentle stretching exercises. For the knees, the most important muscle groups to target are the quadriceps and hamstrings. This is because tightness in these muscles increases the compressive forces at the knee joint and results in increased pain and damage to the joint. Static stretches are preferred whereby the position of mild discomfort is held for at least 15 seconds. Stretches should be pain free and held for longer durations as the muscle becomes more conditioned. This will ensure an increase in muscle and joint flexibility and a reduction in muscle tightness. On a broader scale, maintaining good muscle and joint flexibility reduces the risk of sustaining injuries during physical activities.
