Healthcare for knee pain from all causes consumes a large portion of the health dollars, and research has shown that a large portion of the money is being spent on ineffective treatment. There are vast numbers of treatments for knee pain, and more often than not, patients will go through a long process of trial and error. If the first treatment doesn’t work, the patient will move on to the next, and this will continue until a successful treatment is found or the patient gives up. In some cases, one type of treatment will be used too long without success. Physical therapy is an example of a good treatment for many conditions; however, it can be ineffective if the causative factor of the pain is not addressed. In these cases, it would be better to have the physical therapy first to identify the cause of the pain, and then to follow with treatment of the causative factor. This could save a lot of time, money, and frustration for the patient. A system of treatment that encompasses the needs of every patient and does so in an efficient manner is sorely lacking. This guideline is an attempt to cultivate such a system.
Knee pain is one of the most common forms of pain and can lead to a decrease in quality of life. Knee pain can result in difficulty walking, climbing stairs, and getting out of chairs. The affected individual may also have difficulty participating in recreational activities, which can result in loss of muscle strength, endurance, and flexibility. This ultimately can lead to an increased risk of developing conditions such as arthritis. The knee is a complex joint, so there are many potential causes of knee pain. While it is tempting to simply ignore the pain and hope that it goes away, this strategy rarely results in a resolution of the problem. Instead, it is more likely that the pain will persist and possibly become worse. Oftentimes, acute injuries lead to chronic pain due to improper healing. In these cases, it is especially important to seek treatment that will ensure proper healing of the injured tissue.
What is Knee Pain?
- Patellofemoral syndrome: Pain when you are climbing stairs and sitting with knees bent for long periods.
2. Patellar tendinitis: This is an inflammation and injury to the tendons that connect your kneecap to your shinbone. It is also a common injury for athletes.
There are many types of knee pain. They can be further classified based on the cause of the pain and the location of the pain. Below, we list the main types of knee pain and briefly describe each one.
Some knee pain is mild and can be self-treated at home, while other knee pains can be chronic and require more serious treatment to help prevent further injury that will result in more pain. In serious cases, knee pain may not subside and may begin to hinder your mobility. This will result in the use of mobility aids to help reduce the stress on the knees and prevent further injury.
Knee pain is a common complaint that affects people of all ages. Knee pain may be the result of an injury, such as a ruptured ligament or torn cartilage. Medical conditions including arthritis, gout, and infections can also cause knee pain.
Importance of Addressing Knee Pain
The final and most severe consequence of change joint environment is the development of osteoarthritis. This is a condition in which the cartilage is completely worn away and the bone ends up grinding painfully on bone, to which the only solution is knee replacement surgery. It is therefore of great importance to address knee pain as soon as it has occurred in an attempt to halt any degenerative changes that may have taken place.
The next thing that occurs is that we experience swelling or joint effusion as a result of the body attempting to clear the joint environment of debris so that it can repair the damage. Unfortunately, this procedure is not very efficient and in the knee, it often leads to locking and instability as a result of loss of cartilage which is the body’s attempt to avoid the painful bone-on-bone contact that would occur with no protective layer of cartilage.
The first thing that occurs when the joint environment changes is that cells are released into the local environment. These cells, when blood, serum and damaged tissue are released into the environment as a response to injury or deprivation of nutrition to an area, cause pain. This pain is usually exaggerated, sharp and intermittent.
Degenerative knee pain occurs when there is a structural change within the joint. The cells that make up the cartilage and the synovial fluid are no longer capable of maintaining a healthy and comfortable joint environment. This is usually a result of prior trauma with insufficient healing time, such as an acute knee injury or a slight abnormality in the way the knee is aligned which causes the joint to wear down unevenly.
Singaporean Specialist Recommendations
The key to a diagnosis often lies in further special investigations. X-rays are an essential first step and often provide a wealth of information. They should be performed weight bearing and non-weight bearing. We must always remember, however, that the x-ray must be clinically correlated. An MRI provides even more detailed anatomical information and is particularly useful in soft tissue injuries. It is now often the investigation of choice before surgical intervention. Regular ultrasound also provides detailed information. CT scans are useful for looking at bony detail, especially around the knee prosthesis. However, it is important to take note that investigations often provide a lot of information, but it is the correlation of clinical signs and symptoms that is most important. This allows an accurate formulation of a problem list, a definitive diagnosis, and subsequently a relevant treatment plan.
Following that, it is important that a basic neurological and vascular examination is performed to screen for any associated low back or vascular pathology. This is then followed by a detailed knee examination looking specifically for any deformity including fixed flexion or valgus/varus deformity, any muscle wasting, any abnormal gait pattern, and signs of effusion.
For the diagnosis and evaluation of patients with knee pain, Dr. Chng recommends that a detailed history of the knee pain is obtained. This includes the nature (onset, duration, frequency, progression, previous history of knee pain), the site of pain (localized or generalized), the presence of any aggravating or relieving factors, and the character of the pain. Any associated symptoms such as giving way, locking, swelling or specific joint symptoms of other diseases should also be noted.
Diagnosis and Evaluation of Knee Pain
Only when the above investigations are inconclusive and there is a high suspicion of soft tissue (ligament, meniscus, cartilage) or bony pathology, should an MRI be requested. An MRI is a very expensive investigation and should not be requested routinely for any knee pain. An accurate clinical diagnosis coupled with a focused MRI request will result in the most effective use of resources. A definitive diagnosis is essential as it will guide appropriate treatment and prevent the mismanagement of a patient. For example, an inward buckling giving way knee in a middle-aged patient with medial joint line pain but without an appropriate clinical history of an acute meniscal tear would not benefit from an arthroscopy. An MRI showing a large complex tear with locking symptoms in a young patient with no significant chondral damage would, however, benefit from an arthroscopy and meniscal repair.
For example, a posteroanterior knee x-ray of an elderly patient with medial arthritis and medial joint line pain will confirm the presence of medial joint space narrowing and osteophytes, and would indicate that the pain is due to medial compartment osteoarthritis. An alternative diagnosis would be an insufficiency fracture of the medial tibial plateau and an x-ray would reveal a joint depression and subchondral sclerosis. The initial diagnosis of patella tendon pain in a basketball player could be confirmed with an x-ray showing lower pole patella spurring. Malignancy and infection are rare causes of knee pain, but could be causes of persistent knee pain especially with a background history of cancer or systemic sepsis. Any unexplained persistent knee pain could thus warrant further investigation with ESR and a plain X-ray to exclude sinister pathology.
After taking a detailed history, the next step is to narrow the differential diagnosis through a suitable physical examination. This is especially important as there are numerous soft tissue and bony structures around the knee that could be potential sources of pain. The final diagnoses can then be confirmed with the results of investigations. The most useful and cost-effective investigation is plain radiographs which should be performed routinely. From our specialist clinic audit, we found that there were far too many referrals with inappropriate requests for MRI, resulting in a waste of valuable resources. An X-ray can confirm clinical suspicions and rule out differential diagnoses.
The approach to any patient or athlete with activity-related knee pain must begin with a detailed history and physical examination. This would then be followed up by investigations that are useful. Health professionals will diagnose the knee pain through checking for the site of pain, onset, duration, radiation, previous episodes, history of trauma, locking, giving way, and swelling. These are all valuable pointers to the underlying pathology. For example, an insidious onset of anterior knee pain in an overweight middle-aged woman is highly suggestive of patellofemoral degenerative change. In contrast, a sudden severe pain in the knee and giving way during a football tackle may indicate an acute anterior cruciate ligament rupture.
Non-Surgical Treatment Options
In obese patients, weight reduction plays a significant role in relieving knee pain. Weight loss leads to decreased compressive force across the joint, hence reducing pain and enhancing mobility. This would effectively slow the progression of pathology in the knee joint. A loss of just 5.1 kg of body weight is associated with a 50% lower risk of symptomatic osteoarthritis in the contralateral knee.
Weight control
Simple painkillers can be effective as an adjunct for therapy to allow greater participation in an exercise program. Non-steroidal anti-inflammatory drugs (NSAID) are commonly used to treat knee pain, and these also help to alleviate inflammation of the knee joint. Glucosamine and chondroitin sulfate are commonly thought to help relieve symptoms of osteoarthritis, although studies have shown variable evidence to support their efficiency.
Medications
Physiotherapy is a treatment of preference. It is aimed primarily at the lower limb to regain strength and movement. When the muscles are able to function effectively, it will help to ensure the knee joint is well protected. It is designed to help alleviate pain and strengthen the knee to prevent further pain or mobility loss. Exercise is a key component of both physiotherapy and the prevention of knee pain or mobility loss. A good exercise regime means cardiovascular workouts, weight training to maintain good muscle strength and endurance, as well as flexibility exercises for a good range of movement in the knee joint. Both physiotherapy and exercise are most beneficial to those who suffer from ligament or meniscal injuries, mild osteoarthritis, or those who have undergone surgical treatment and are looking to prevent further problems.
Physiotherapy/Exercise Regime
The options a person can choose from in treatment so as to avoid surgery are several. We will discuss the various non-surgical treatment options available and provide an insight into the different scenarios where these treatment options will be most beneficial.
Non-surgical treatment options for “Knee Pain and Mobility Aids: Recommendations from Singaporean Specialist”
Surgical Treatment Options
The open patella realignment procedure is only recommended if there are episodes of giving way due to patella subluxation in the absence of significant chondral damage. This is questionably a beneficial procedure, but again the recommendation is specific. High tibial osteotomy is a poor long-term treatment for pain relief in an older arthritic population. The high tibial osteotomy is only specifically recommended if there is mild varus malalignment in a patient with significant functional impairment and no chondral damage in a bid to delay progression to a total knee replacement. In this case, the patient must be informed of the relative merits compared to a total knee replacement.
In summary, these evidence-based recommendations are a concise and clear guide for the management of knee pain in the older patient. They are a distillation of available current evidence into simple recommendations that can be used in general practice. They are pertinent to our patient population in Singapore and cover a widely prevalent problem. If a conservative approach for the knee is medically unproven and has been discarded by the elite athlete, then consideration should be given to a surgical approach. This, in itself, again is a strong patient-specific recommendation.
This specialist’s main indication for surgery in her patients is functional impairment. When surgery is considered, the findings do guide the type of surgery offered. She notes that surgery must be tailored to the individual patient. Surgery for problems that have a high spontaneous improvement rate or have a low long-term symptomatic outcome are generally not advisable. This principle is the basis for the recommendations made when considering surgery for each of the specific problems outlined above. This is the part of her recommendations that I find authoritative and useful to the GP in Singapore. If referral to a specialist is needed, the patient can go armed with relevant questions and the GP can feel confident he has sent the patient at the right time and to the right person.
Choosing the Right Mobility Aid
The right mobility aid is one that fits both your particular mobility requirements and your individual lifestyle. This might mean that you need more than one type of aid. In some cases, using just one type of aid may not be possible. For example, a long cane cannot provide the support needed to stand up from a low chair. In this case, a quad cane or a walker with a seat may be more appropriate. Temporary injuries or changes in your condition tend to require different types of aids. For example, if a flare of arthritis in the knee has made it difficult to climb stairs, a cane or crutch might be used for a short period of time. A knee injury often means that a brace is required until the knee has healed. It is important to discuss with a therapist or physician what specific functions the aid needs to fulfill. This will help in determining what type of aid is best for the short and long term.
Types of Mobility Aids
Mobility aids not only enable the user to move about but increase safety. This is particularly important for stroke patients and the elderly who have lower limb weakness. The aids reduce falls and subsequent injury. A study has shown that elderly patients who sustained a hip fracture had a significantly higher recovery rate when using a walking aid.
Walking frames are four-legged structures that provide the maximum support for a user. They are more suitable for indoor use as they can be difficult to maneuver outside and require more effort to lift and move. Frames are available with wheels, which increase maneuverability. Frame users with greater disability can purchase wheeled walkers that have a seat for resting.
Walking Aids Walking aids are designed to provide support and balance to the user. They range from simple walking sticks to walking frames. A walking stick is the most simple aid for walking. It provides balance and support to the user and is available in various designs. Single-point sticks are lighter and provide less support compared to quad sticks. The base of the sticks can be designed to suit various needs, such as curved or tripod bases. Sticks are made from various materials to give different textures and strength. This can be important for users with hand disorders. Price and quality vary greatly.
Mobility aids are designed to help the elderly, disabled, and handicapped move around. Walking is a basic human function, and loss of mobility has a major impact on the quality of life. It is important to understand the needs of the user and the types of aids available before selecting a mobility aid. Mobility aids can generally be divided into three categories: walking aids, wheelchairs, and scooters.
Factors to Consider in Selecting a Mobility Aid
Physiological and functional factors – The choice of mobility aid should be influenced by the overall functional ability, mobility requirements, and the duration of an individual’s activity. This is due to the fact that the physiological stress or load on a body segment is a major determinant of the assistance required, with greater stresses and longer durations of activity requiring more assistance. An aid which unloads a specific body part or joint may be needed for people requiring partial weight-bearing restrictions or following injury to an isolated body segment. The coordination and steadiness of an individual should also be considered, with less coordinated individuals having a higher fall risk and requiring a more stable aid. Finally, the upper limb strength of an individual using a walking aid is an important factor often overlooked, with some walking aids significantly increasing the upper limb joint moments and muscle forces. This can lead to a faster onset of joint muscle fatigue and exacerbation of an upper limb condition.
This section must inform the reader that the selection of an appropriate mobility aid is a multifactorial process. Factors which should be considered encompass the physiological and functional requirements of the patient, as well as environmental and societal factors. With the interaction of these factors being so complex, it is critical that an individual assessment is conducted by a person with a good understanding of the conditions and using the aid. This will help to ensure that the aid recommended is well suited to the individual and is sufficiently matched to their needs. The use of an aid which is not well matched to the patient or one which is under prescribed can lead to dissatisfaction with the aid, non-use of the aid, and wastage of resources. This is a common problem with many people who obtain a walking stick and then progress onto a quad stick or walker, continuing to use an inappropriate number of sticks usually as a result of incorrect advice from a healthcare professional. In some cases, a person may use a stick for too long and can interfere with a unilaterally lower limb surgery rehabilitation program. An understanding of the following factors will assist clinicians in making an appropriate recommendation.
There has been substantial progress in the field of biomechanics and biological joint replacement. For optimization of healthier joints, we need to understand the adverse effects of excessive mechanical loading in the knee joint and the changes in loading after ligament injuries. Furthermore, understanding the effect of unloading on a degenerated joint and the potential clinical implications of gait modification will provide us with the knowledge to develop improved treatments and preventive strategies. Advances in imaging and gait analysis techniques will enhance our ability to study in vivo joint loading and provide a more objective assessment of functional outcomes following injury and intervention. This will allow closer scrutiny of the efficacy of current osteoarthritis treatments, recent advances in cartilage repair, meniscal transplantation and ligament reconstruction, and biological joint replacement on the knee joint’s mechanical environment. As most of these techniques are relatively new, existing or in development, we are optimistic that joint effort in the related research will translate into substantial reduction in the prevalence of knee osteoarthritis.