A Roadmap to Recovery: Treatment Plans from Singapore’s Knee Pain Experts
Any attempt at addressing the problem of chronic pain must, to some extent, be considered a roadmap. The experience of pain leads the patient on a journey all too often filled with dead-ends, detours, and u-turns. The patterns of seeking relief often mimic the experience of traveling in a foreign land. There are moments of clear understanding and a sense of moving forward. There are also times of confusion, misinformation, and unanticipated delays. The idea of a roadmap to recovery is to provide a plan and a set of directions aimed at optimizing the chances of a smooth and successful journey. In the case of chronic pain, successful treatment and rehabilitation is the process of finding the right turns and the correct road to recovery. It is the intention of this Special Issue to provide the reader with a set of directions, potentially a roadmap, for the treatment of knee pain. Written by a combination of clinical and research experts in the field of knee pain, each article provides a state-of-the-art account of treatment methods and their rationale. A special effort has also been made to provide information which is directly translatable into practical strategies for the clinician and the patient. This is the first of two complementary articles. The present article considers the broader context of treatment decisions and the issues involved in determining best evidence practice. This is illustrated through discussion of the complex interplay between evidence and clinical practice in the decision-making process for a 58-year-old female with anterior knee pain. A case has been chosen to provide a useful link between the issues raised in the introductory articles and the content of the reviews that follow. The case is split into two parts… steps, and reduce the likelihood of predictability. With that being said, enhancing equity through education, which soothes the bruised and battered spirit of the oppressed, is a long and arduous struggle but an essential first step in changing a divided society. In recent years, the development of clinical guidelines has been recognized as a significant step toward improving quality of care and patient outcomes. A growing number of medical specialties have invested great time and resources into developing guidelines aimed at helping clinicians and patients make treatment decisions based on the current best evidence. From the outset, it is essential to keep in mind that the purpose of treatment is the restoration of functional ability and participation in desired activities. This may seem a self-evident statement, but in clinical practice, it is all too common for treatment to be directed solely to the relief of pain and other symptoms. A recommendation has been made to develop guidelines for guidelines on the basis that it can improve the quality of guidelines and address the current methodological variability. The case of Mrs. J, a 58-year-old retired school teacher with chronic anterior knee pain, serves as an excellent example of the complexities involved in determining best evidence practice for treatment.
Understanding Knee Pain
Recognizing the knee pain is the nervous system’s way of protecting us by decreasing muscle activation, whether through inhibition, pain, or by compensatory strategies (such as walking with an antalgic gait, or developing a Trendelenburg lurch). Knee pain can be due to a local injury or referred pain. Local injuries are often the result of direct trauma (bruise, bone fracture, or ligament sprain/tear, muscle strain/tear), or secondary to repetitive overload (tendinitis, or meniscus and articular cartilage degeneration/tears). Referred pain to the knee often originates from the lumbar spine, but can also be from various pelvic and hip pathologies. An example is the poor knee function experienced after an ankle sprain due to inhibited gluteal muscles from the ankle pain and loading strategy alterations. Regardless, it is vital to have an accurate diagnosis. This involves not only identifying the pain generator, but also identifying the faulty movement and loading mechanisms, biomechanical contributions, and any external factors that may exacerbate pain in order to design an effective treatment plan.
Causes of Knee Pain
Another condition is gout, which is a common type of inflammatory arthritis that is very painful. This condition is due to a metabolic disorder in which there is an abnormal buildup of uric acid, forming urate crystals that are deposited into the joints and other tissues. A gout attack often happens suddenly and at night, and the pain and swelling are usually very intense.
Another serious condition is a knee infection. This can be a general infection or viral infection, but it can also be an infection within the joint itself. People with a history of knee replacement surgery or people with poorly controlled diabetes are at higher risk of developing a joint infection. Site pain, joint stiffness, and other systemic symptoms can indicate an infection. This is a serious condition that requires medical attention as soon as possible, as an infection, if left untreated, can cause significant damage to the joint and surrounding tissue.
Another common long-term knee condition is Rheumatoid Arthritis. This is a chronic systemic disease that primarily affects the joints but can also affect other body organs. It is an autoimmune disorder in which the body’s immune system attacks healthy tissue. This disease is different from osteoarthritis, which is a degenerative joint disease often affecting middle-aged and older individuals. It can affect people of all ages and often causes pain, stiffness, and loss of function in affected joints. An effusion, warmth around the joint, and the feeling of sickness and fatigue are common symptoms. This condition causes knee pain and can lead to eventual arthritis in the knee joint.
Osteoarthritis is the more common knee arthritis, affecting the “wear and tear” and degradation of knee cartilage. It mostly affects middle-aged and older people, as the cartilage in the knee diminishes over time, causing pain and swelling. People who have had previous meniscus tears, ligament injuries, or other significant knee injuries are more likely to develop osteoarthritis. A bone deformity can also cause pain and cartilage degradation. A varus or valgus knee, where the knee is either bowlegged or knock-kneed, increases the risk of developing osteoarthritis on the affected side of the knee. Typical osteoarthritis often involves pain, particularly with weight-bearing exercise, stiffness, and limited joint movement. (Note: This creates a mechanical block in which the person is not able to fully straighten or bend the knee).
Underlying conditions: Knee pain is often caused by an underlying condition. Some of these conditions are more mechanical in nature, affecting how the knee moves or the alignment of the knee. Others affect the integrity of the joint and its surrounding tissues, causing more pain and inflammation.
Overuse injury: Some knee pain is caused by overuse. Muscle strains and tendinitis can produce pain and swelling from an overused or stressed muscle, causing pain around the kneecap.
Sudden injury: A bone fracture, torn ligament, or torn tendon can cause knee pain. Injuries like torn ligaments or torn meniscus can result from a mechanically traumatic event, a powerful twist, or an overextended knee.
Knee pain can be caused by a sudden injury, an overuse injury, or by an underlying condition, such as arthritis.
Symptoms of Knee Pain
Pain located on the front of the knee can be due to the roughening of the cartilage on the underside of the knee cap. When climbing stairs, sitting down for long periods of time, or getting up from a seated position, pain is likely to occur. This condition is common in adolescents and young adults, but may begin in the teenage years. If the articular cartilage has begun to break down, a feeling of the knee giving way can become more pronounced. This is often a result of a cyst forming in the damaged area due to increased pressure on the healthy cartilage. Failure to treat this kind of injury can be detrimental to the knee. Tendon injuries, loosening of the knee, and weakness on the thigh muscles can occur along with extensive damage to the articular cartilage. This could lead to a total knee replacement in extreme cases.
Knee pain symptoms typically include a dull ache or discomfort in the knee, occasional locking, clicking or catching, sudden sharp pain with activities, and the inability to fully straighten the knee. Swelling may be absent or quite pronounced and in some cases where the meniscus has been injured, a “giving way” of the knee may occur. The knee may be stiff in the morning, a condition that is usually no more than 30 minutes. In more severe cases, pain can be constant. The location of the pain can also give clues as to the origin and cause of the knee pain.
Treatment Options for Knee Pain
If the pain is too severe, surgery may be a necessary evil. There are a few options depending on the injury. The most common knee surgery is an arthroscopic surgery. This is a minimally invasive surgery that is used to treat many different knee issues. Partial knee replacement is a surgery that can be used to only replace the parts of the knee that have been affected by arthritis. This is beneficial because it has a shorter recovery time than a total knee replacement. However, if the arthritis has affected the whole knee, then a total knee replacement may be necessary. This is generally a last resort and is not recommended for those that are very young because the replacement knees have a lifespan of 10-15 years.
Surgical Treatments
There are many nonsurgical treatments for knee pain. Often the best way to treat the pain is to avoid overusing the knee. Rest and icing the affected area are helpful. There are also many drugs that can be used to treat knee pain. Acetaminophen and NSAIDs are useful. Those with more severe pain can use corticosteroids. Hyaluronic acid or platelet-rich plasma compose injections that can be used to treat the knee. These can help young patients and even delay the need for surgery. Physical therapy is a key part in getting the knee back to health. Physical therapists can work on a program specific to the patient that will help build the strength of their knee and avoid surgery. For any other knee pain related to sports or exercise, altering the activity level that caused the pain may be helpful. Finally, losing weight can have a big effect on knee pain for those that are overweight.
Non-Surgical Treatments
Simple painkillers like paracetamol can be effective. Anti-inflammatory medication is often more effective for pain coming from inside the knee joint. It can be taken as tablets, or using creams or gels applied directly to the skin over the painful area. Tablets can be hard on the stomach, especially in older people. They are generally best taken with food, and it can help to also take medication to protect the stomach. In this situation, taking the tablet after food, and using a gel in addition can sometimes work well. If the anti-inflammatory medication is being used long-term, it’s important to review the dose and type of medication with a knee pain doctor Singapore, to balance the benefits against potential side effects on the stomach, kidneys, or the increased risk of heart problems. Some people will get significant pain relief from stronger medication like codeine or tramadol, but these are best avoided due to risk of addiction and other side effects. Few people will have a clear indication for using opiate-type medication. Other more specialised medications can sometimes be used for particular knee conditions, for example gout. Always discuss medication options with a doctor.
Non-surgical treatments can be very effective in relieving the pain and disability of knee problems. They are also low risk, and in general, relatively low cost. There are 3 main options: medications, physical treatment, and knee injections. Sometimes a combination of 2 or even all 3 will be used.
Surgical Treatments
Surgery is the right option for some patients and can provide excellent results. It is most effective for patients with mechanical symptoms (locking, clicking) and those whose knee pain is a result of damage to a specific part of the knee, most commonly the meniscus. It is less useful for patients with rheumatoid arthritis. Many different types of surgery are available, the most common being arthroscopic (keyhole) surgery. This is usually performed as a day case, and most patients are able to go straight back to weight-bearing, with the aid of crutches for 1-2 weeks. The recovery time is generally quicker than with open surgery. Arthroscopy can be used to remove loose fragments of bone or cartilage, to trim a damaged meniscus, or to smooth rough cartilage, and is usually very effective in relieving symptoms. More extensive damage to the articular cartilage might be treated with a type of keyhole surgery where small holes are made in the bone underneath the cartilage to stimulate scar tissue to form, which will be fibrocartilage. This is a close imitation of articular cartilage but is less effective in older patients, as cartilage heals less effectively with age.
Rehabilitation and Recovery
Whether you have had a total knee replacement, an arthroscopy with some repair to the joint surfaces or a soft tissue injury, the principles for rehabilitation are the same, though the exercises may need to be modified for some procedures. Initially, the aim is to protect the healing tissues and gradually progress to more functional exercises. Your physiotherapist will help you to regain full knee movement and provide you with a series of strengthening exercises to improve the strength of the muscles around your knee and lower limb. A core stability or exercise ball program may also be indicated to improve your general balance and stability. Finally, when you have achieved sufficient strength and control, a gradual return to your previous activities such as walking, running or sport can be commenced. Although the specific details of your rehabilitation program may vary, the end goal will be the same.
The goal of the rehabilitation program is to help you return to your normal activities. This will include the treatment of your symptoms and the building of your general strength and fitness. The physiotherapist will use various treatment techniques to control your pain and swelling. These may include hands-on treatments such as massage and acupuncture, taping or electrotherapy. You may be given advice about ice or heat treatment and exercises to do at home.
Rehabilitation Exercises for Knee Pain
Phase III (advanced strengthening) focuses more on advanced strengthening and return to the patient’s previous level of function. Exercises may include sports-specific exercises or an exercise bike/rowing machine to improve the patient’s cardiovascular fitness.
Phase II (subacute stage) focuses on increasing strength and endurance of the quadriceps and hamstring muscles. Closed kinetic chain and open chain exercises for the quadriceps and hamstring muscles are done. Open chain exercises for the quadriceps are preferred as they produce less force through the patellofemoral joint.
Exercises are divided into different phases to allow progression of the strength and stability of the knee. Phase I (acute stage) focuses on reducing pain and inflammation and increasing the range of movement of the knee. Isometric contractions can be done for the quadriceps 2-3 times per day to prevent wasting of the quadriceps muscle.
Rehabilitation exercises will help to increase the strength of the muscles that support your knee, increase the flexibility of the knee, improve the stability of the knee, and strengthen the knee joint. The ultimate benefit is to decrease pain and increase function so that you are able to cope with the demands of normal daily activities.
Post-Surgery Recovery Tips
Walking Aid: You may require a walking aid such as crutches or a cane. The decision to use these and the duration of their use will depend on your surgeon and your progress. High step walking with the crutches or a solitary crutch on the non-operative side is normally suggested.
Movement: While minimizing the total load going through your leg, exercising your muscles and bending and straightening your knee is essential. By contracting your thigh muscles and pushing the back of your knee into a small towel roll beneath your heel while sitting, you can maintain your straight leg. Bend your knee cautiously and slowly, and if this causes swelling or pain, cease the activity. Gently work up to 10-15 minutes of knee bending in the morning and at night. Step exercises and continuous gentle walking are also beneficial.
Compression: If swelling in your knee and below the knee is substantial, a compressive wrap a couple of inches below the knee can aid in reducing swelling.
Ice: To cool the knee and reduce perpetual swelling and pain, ice your knee for 15-20 minutes every 2-3 hours for the first few days post-surgery. To avoid frostbite, place a cloth or towel over the ice pack. After 72 hours, ice 15-20 minutes three times per day as required.
Rest, Splint & Elevate: You require a splint on your knee at night for six weeks for comfort and protection. Additionally, during the day for the first week or two post-op, elevating your leg several times above waist level (e.g. onto chairs) can help decrease swelling and pain.