It is important for someone who suffers from knee pain to seek medical attention to obtain an accurate diagnosis and an appropriate treatment plan. This is crucial in order to restore an individual’s quality of life and prevent further injury to the knee. Failure to seek an accurate diagnosis and appropriate treatment can lead to prolonged pain and further injury. This often leads to more aggressive forms of treatment and a reduction in the individual’s level of activity. A decreased level of activity often leads to other health-related issues that can affect an individual both physically and psychologically.
Knee pain is a common complaint in over half of the population, and it affects an individual’s quality of life and mobility. The knee is a complex joint with many components, making it vulnerable to a variety of injuries. These injuries can happen suddenly (acute), such as an injury to the anterior cruciate ligament (ACL), or overuse injuries, such as iliotibial band syndrome. In the elderly, knee pain is often caused by degenerative disorders such as arthritis. The anatomical alignment of the knee is disrupted (with or without a specific injury), most commonly by a medial collateral ligament injury and a meniscal tear, both of which are often associated with localized pain and swelling. Each of these injuries can cause various forms of knee pain and can be addressed with different treatments.
Overview of Knee Pain
The medical condition ‘meniscus tear’ is a common injury to the knee, often occurring in sport. The meniscus is a rubbery, C-shaped disc that cushions your knee. Each knee has two menisci, one at the outer edge of the knee and the other at the inner edge. The menisci keep your knee steady by balancing your weight across the knee. A torn meniscus can lead to mechanical locking of the knee, and/or a clicking or a giving away of the knee. Unfortunately, not all people with a torn meniscus have knee pain or even swelling. This can make the diagnosis of a tear difficult. In the case where there is significant knee pain, swelling, or catching of the knee, surgical repair may be considered to prevent further damage to the knee joint. This pain can also be discomfort in the long term, possibly due to a gradual wearing out of the meniscus with old age.
Injury is the most common reason for knee pain. The anterior cruciate ligament is one of the more commonly injured ligaments in the knee. This is due to quick stops and changes in direction, such as when playing soccer, basketball, tennis, and other high-demand rough sports. This will often cause the ligament to ‘give away’. This is a symptom of the knee feeling unstable. If an unstable knee is not treated, further damage to the knee joint may occur. A change in the rotational forces at the knee during impact is another cause of ACL injury. This can occur during a low-contact activity if there is direct trauma to the knee.
Articular or joint pain can occur in the knee due to many different types of injuries or conditions. An injury can cause the smooth cartilage to break off into a loose body. This loose body will float or drift into the joint and cause an interference to movement. This type of interference often causes the knee to lock. Pain may gradually build up over a period of time due to degeneration of the articular surface, which is commonly known as arthritis. An inflammation of the joint may occur due to an infection, which is one of the most painful and disabling problems. There are several different urinary and metabolic system disorders known as systemic diseases, which can be linked to joint pain. These diseases can affect the function and movement of the kidneys, causing fluids to build up in different body parts. In the knee, the fluid will accumulate, thus causing swelling and pain.
The knee is an important part of the body, as it is responsible for two important functions: supporting the body’s weight and enabling movement. Knee pain is a common symptom that affects people of all ages. Knee pain can occur in any of the structures, including the knee joint, the kneecap, or the ligaments and cartilage of the knee. Some of the more common reasons for knee pain are injuries, mechanical problems, arthritis, gout, infections, and various types of bone tumors. Injuries, mechanical problems, and arthritis are the most common causes of knee pain. Our treatment options for knee pain at the Singapore Sports and Orthopaedic Clinic are very varied and effective. These options will be made available depending on the nature of the knee pain and/or severity of the injury.
Importance of Seeking Treatment
If compared, the treatment for knee pain is not as expensive as the emotional and economic impact it can have on the person. It has been observed that if the knee pain is left unchecked for a period of time, it can change the alignment of the leg because of the discomfort and change in walking due to pain. This can further lead to more serious problems. Also, delaying the treatment can cause early onset osteoarthritis, which brings about chronic pain and discomfort in the knee. Osteoarthritis is a long-term issue and can sometimes need to be managed with medication and pain management. In a worst-case scenario, the pain can be so much that the person may have to go for a total knee replacement.
In as much as knee pain can be a small or big issue, it’s of extreme importance to have it checked quickly. This is simply because delaying in treating the issue can cause serious damage to the knee and can sometimes require a major surgery for its correct function. In some cases, it may also lead to so much discomfort and pain that the person must have to compromise with his lifestyle and activities, which may have harmful effects on his professional life.
Non-Surgical Treatments
Physical therapy involves specific exercises which aim to strengthen the thigh and leg muscles in order to restore stability to the knee. The exercises are of varying difficulty and are tailored to the patient’s individual needs. Usually, the harder exercises will only be introduced well into the treatment. An example of a simple exercise which may be prescribed is the straight leg raise. This exercise will work the quadriceps without putting undue stress through the knee joint itself. The patient would simply lie on their back, tighten the muscle on the front of the thigh, and lift the leg up so it is in line with the other leg. This exercise should not be performed by patients with patellofemoral problems. As the patient progresses, the exercises will become tougher and may involve gym equipment. In some cases, a physiotherapist may use different techniques such as massage or ultrasound to relieve pain and muscle tightness before starting on the exercises. The progression and the response to treatment is monitored at regular intervals, and the treatment plan may be modified at short notice. A good therapist will have the patient’s best interests and a positive outcome at the forefront of their treatment.
Physical Therapy
If a person has clear instability in the knee or has suffered traumatic injury causing ligament tears, they will likely require intense rehabilitation and surgical reconstruction. This will be based on similar principles, but certain techniques will be modified or restricted depending on the specific injury and the post-operative rehabilitation protocol.
Manual Techniques: Hands-on stretching and mobilization techniques can help to maintain or improve mobility of soft tissues and joints. It can be painful, but it is a crucial part of rehab. High tibiofemoral joint (the joint between the tibia and femur) pain is often caused by excessive joint compression, and manual therapy can help alleviate or prevent further aggravation of this condition.
Strength Training: The quadriceps and hamstring muscles play a key role in protecting the knee, as do the muscles in the hips and lower leg. Part of the reason people develop knee pain is due to muscle weakness in the leg. Strengthening these muscles can reduce stress on the knee.
Stretching: The knee is one of the more complicated joints in the body. Stretching is important to make sure the joint is working to its full potential. This is done passively where the therapist moves the joint, and active where the patient does the exercise themselves.
Physical therapy is an essential part of most rehabilitation programs recommended for knee pain. Physical therapists use different techniques to increase strength, regain mobility, and help return the patient to his or her pre-injury lifestyle. This is done through the following:
Medications and Injections
If medications and physical therapy do not provide relief, knee pain specialist may suggest injections into the knee. Some people are helped by injections of hyaluronic acid, a substance found in normal joint fluid that lubricates the joint, absorbs shock, and allows the joint to work properly. Available evidence suggests that this treatment is most helpful in patients with milder arthritis. Another type of injection uses corticosteroids. Corticosteroids are powerful anti-inflammatory hormones. They are very effective at reducing inflammation and can be injected into the joint to relieve the inflammation and pain of arthritis. Corticosteroids can have side effects and repeated use of these injections is discouraged. A newer type of material to treat chronic, painful tendon injuries, and arthritis is Platelet Rich Plasma (PRP). A large amount of human blood is withdrawn and the platelets are separated from the red blood cells and are then concentrated. The platelets release many growth factors. This process is thought to speed up the natural healing factors. This option is still relatively new and more studies are being done to prove this treatment to be effective.
Assistive Devices
For patients with no unusual or special needs, the initial use of simple walking supports is often effective. A cane designed for the hand opposite the affected knee can reduce the load on the affected knee by approximately 10-15 kg. This is a straightforward and effective way to decrease pain and stress on the knee joint, but many individuals resist the use of a cane, feeling that it will make them seem feeble. In these cases, a determination of the patient’s willingness to use a cane and the specific reasons for resistance can often allow for problem-solving and a successful outcome. A cane should be used only as long as it provides benefit, and patients should be instructed to reassess its usefulness at regular intervals. An improperly fit cane is a common persistent use. The cane grip should be at the level of the patient’s wrist when the arm is held straight alongside the body, and often a simple demonstration of this point allows for continued success with cane use.
Assistive devices help reduce pain and stress on the knee joint. They are prescribed to patients with osteoarthritis, a degenerative condition in which the cartilage in the knee deteriorates over time. The knee joint has a poor blood supply and limited capacity for healing. Osteoarthritis often progresses slowly, and the mild pain it causes can usually be handled through simple measures. When the pain becomes more severe and persistent, the added stress on the knee joint causes further degeneration, and a cyclical process begins that can lead to an increasing lack of mobility and independence. Limiting this vicious cycle is the goal of treatment for knee osteoarthritis, and assistive devices are often an effective way to accomplish this.
Surgical Treatments
At this point, you would have tried a range of nonoperative treatments without success. The information for these largely states that the bigger problem you eventually let yourself get into, the more drastic the surgery you will finally consider. Articular cartilage is the type of tissue that lines the ends of bones where they form a joint. This is smooth, slippery, and allows effortless movement of the joint. Damage to the articular cartilage in the knee has a set trajectory. This can be meniscal tears leading to abrasion of the end of the bone. This can be quite a mechanical problem, best depicted and diagnosed through MRI. Often, these mechanical problems can be improved via a knee arthroscopy. This involves proceeding to a diagnostic arthroscopy and removing loose or damaged cartilage that is debrising over time. This will facilitate better, smoother movement of the joint and, in theory, relieve pain. If the abrasion of the end of the bone is more severe, a procedure called microfractures may be considered. This is a technique of drilling holes into the bone to reach the bone marrow from the central blood supply to the damaged ends of the bone. Over the next few months, the holes will fill up with the blood supply and new fibrocartilage tissue (callus-like cartilage) will be produced. This is obviously not articular cartilage but could possibly offer symptomatic relief. This is not yet the best treatment for this potential knee pain problem, but at least it is a method of changing the bone in belief for relieving the pain. The change from damaged articular cartilage to bone often does cause chronic pain. In the event of complete end-stage osteoarthritis, i.e., no articular cartilage or it is just low quality and the mechanical problems are severe, knee replacement is a definitive way to cure activity-limiting chronic knee pain.
Arthroscopy
An arthroscopy is a minimally invasive surgical procedure which involves the insertion of a camera into a knee joint to visualize and diagnose any damage in the joint. The second phase of the procedure involves using this diagnosis to treat the pain. This surgery is performed more on people who are suffering from knee pain. If the underlying medical problem continues to cause damage to the joint, often the result will be damage or tears to the knee joint that can be very painful and debilitating. These problems are more easily treated if they are detected early. The main advantage of arthroscopy is that the patient has smaller cuts and therefore has less pain, shorter healing time, and less scarring compared to some more traditional types of knee joint surgery. Another advantage is that if only the diagnosis phase of the surgery is performed, it is often an outpatient procedure so the patient will walk into the hospital, often walk out the same day, and can return to work the following day. However, the type of treatment the patient will receive after the diagnosis phase can vary immensely. Essentially, the surgeon can repair the joint back to its original state if something that has been damaged is repaired. An alternative treatment might involve the removal of a small piece of something causing damage in the joint. The worst-case scenario for damage in the knee joint is that something is irreparable, which is the case with total knee replacement, where the damaged joint is removed and replaced with an artificial new one. Often this occurs when there is significant damage or pain onset of osteoarthritis.
Partial or Total Knee Replacement
While TKA has a very good track record of success, the recovery can be prolonged with post-operative pain and swelling. Often, a patient will stay in the hospital for approximately 5-7 days before being discharged to home. A rehabilitation period of formal physiotherapy and exercise regime is often necessary, with time off work and cessation of sporting activities up to 6-12 weeks. Despite this, most patients will experience a significant improvement in knee pain and function from 3-12 months following surgery. However, it is still advisable to avoid high impact or strenuous activities such as running or contact sports, which may accelerate implant wear and reduce the lifespan of the implant.
Partial or total knee replacement is a surgery to replace the knee joint with an artificial implant. For most people, knee replacement provides relief from pain and improved mobility, enabling them to return to their normal activities. In knee pain Singapore, the most common type of knee replacement is Total Knee Arthroplasty (TKA). Often, TKA is suitable for severe knee arthritis and those aged over 65 years. However, a significant proportion of patients under the age of 65 suffering from various arthritic conditions may also receive benefit from TKA. Often, a decision to proceed with TKA is based on the severity of symptoms, clinical and radiographic findings, functional disability, and medical health.
Advanced Treatment Options
Regenerative medicine is an innovative treatment that uses biological substances to promote the new growth of cells or body tissues, in order to restore its optimal functional level. It is a simple concept but involves a complex process. This high technology treatment offers a promising outcome and is rapidly developing with broad prospects in the medical field. It is an advanced treatment for knee arthritis as it gets to the root cause of the problem to alleviate pain and improve the condition of the knee. Traditional treatments only serve to provide temporary relief. This treatment is suitable for those who have early signs of arthritis or a cartilage defect. Cell therapy is a regenerative procedure used to promote the healing process. An example of this would be the use of platelet-rich plasma (PRP). This is a process in which blood is drawn from the patient and then centrifuged to segregate the platelet-rich plasma. The concentration of the plasma is then injected with activated platelets into the site of injury or damage to promote and accelerate the healing process. This treatment has been found to reduce pain and promote knee function in patients with mild osteoarthritis. In a more complex procedure known as regenerative cartilage repair, the body’s inherent cell-making ability is used to reconstruct new cartilage. This is achieved when doctors harvest a small amount of articulating cartilage from the patient’s knee using a minimally invasive option and then culture the cells to form new healthy cartilage tissue to be re-implanted back into the chondral defect. Studies of this new procedure have found positive outcomes and satisfaction from patients, resulting in an improvement of knee function and significant relief of pain for those with cartilage defect lesions.
Regenerative Medicine
The treatment options for damaged articular cartilage have been very limited and have not been successful in regenerating articular cartilage in a lasting way. However, it is believed that regenerative medicine techniques may be able to cure certain knee injuries and conditions. Tissue engineering is a method by which a tissue scaffold can be created and can serve as a template to generate new tissue in the body. This scaffold can be combined with growth factors and mesenchymal stem cells (MSCs), and when implanted into the body, can regenerate new tissue. In the future, this technique may be able to repair articular cartilage in the knee. Currently, research is being conducted to find a way to culture and expand MSCs and to use growth factors to direct chondrogenic differentiation of MSCs and produce a tissue that closely resembles natural articular cartilage. Other techniques being studied are the direct injection of growth factors into the knee to stimulate new tissue growth and gene therapy. The injection of growth factors has been seen to stimulate new fibrocartilage formation. An animal study has shown that gene delivery of a protein called insulin-like growth factor can lead to enhanced healing of articular cartilage injuries.
Knee pain may be treated with regenerative medicine and is a particularly promising area for researchers because the cartilage tissue in the articular surface has a very poor ability to heal on its own. The surface of the articular cartilage has no blood or nerve supply, so when it is damaged either through acute injury or repetitive use, the damage is often permanent. Osteoarthritis is a degenerative joint disease and is marked by the degradation of articular cartilage. This disease affects millions of people, and while it can be treated in a number of ways, there is no cure, and in severe cases, the damage to the cartilage may require total knee replacement. Articular cartilage is also difficult to replace or repair because of its complex and intricate structure.
Regenerative medicine is a multidisciplinary field that seeks to replace or repair damaged tissues and organs. This field holds the promise of regenerating damaged tissues and organs in the body by stimulating previously irreparable organs to heal themselves. This also may allow for new treatments for diseases, which otherwise would be treated with organ transplant or implantation. The goal of regenerative medicine is to find a way to cure previously untreatable injuries and diseases. A variety of approaches are being used in regenerative medicine. Some of the current and proposed approaches are: tissue engineering, the use of stem cells, and the production of artificial organs.
Robotic-Assisted Surgery
At the present moment, custom jigs are available for use in total knee replacement. Robotic knee surgery provides the technology for partial knee replacement, and this will be the next leap for the evolution of partial knee replacement, which is already less invasive and more conservative than a total knee replacement.
On the day of the surgery, the pre-planned information will then be used as a reference to cut and position the bones with custom jigs and saw blocks. This will eliminate the need to use traditional intramedullary rods and extramedullary alignment guides. With higher accuracy for bone cuts, this will result in less tissue damage and ultimately a less invasive surgery.
Robotic knee surgery allows the surgeon to pre-plan and customize the knee surgery before actually performing it. By using pre-operative 3D computed tomography (CT) scan of the knee, the surgeon can plan the surgery and make detailed assessments. With accurate information about the knee structure, the surgeon can make more precise and consistent decisions regarding implant sizes, orientation, and alignment, which is vital for the long-term success of the surgery.
Robotic-assisted surgery is very widely used, especially in developed countries. The aim of this technology is to advance and improve the current surgical methods to ultimately benefit the patient. Robotic surgery is not applicable to all knee conditions. Not all knee conditions require surgery, and not all surgery is suitable for robotic-assisted surgery.
Minimally Invasive Procedures
Minimally invasive procedures offer an alternative to patients with more severe knee arthritis. Recognized as the most common procedure performed on patients with knee problems, it has proven to be highly successful in the vast majority of patients. The benefit of arthroplasty is the dramatic reduction or elimination of pain. More than 90% of patients who have undergone knee replacement experience a dramatic reduction of knee pain and a significant improvement in the ability to perform the activities of daily living. This dramatic reduction of pain and improvement in function enable patients to make significant lifestyle changes, becoming more mobile and active, improving general health and well-being. This is very significant as it reduces the effects of systemic problems associated with chronic knee pain, such as obesity and associated cardiovascular co-morbidities. The minimally invasive procedure has the same expected outcome as traditional arthroplasty. Arthroplasty involves resurfacing the damaged joint with metal and plastic components. The most common problem is isolated damage to the knee cap. In these cases, a plastic button may be used on the undersurface of the patella. This has an equally high success rate in reducing knee pain and improving patient function. In the early stages of isolated patella-femoral arthritis, options such as high tibial osteotomy or unicompartmental knee replacement may be more suitable. These can be discussed with an orthopedic surgeon with an expected outcome of referral to an orthopedic knee surgeon.
