However, we should also take into consideration the economic impact of the treatment, as knee problems are the third most expensive musculoskeletal disorder, after heart disease and back and neck pain. With a wide array of treatments available and considering its economic impact, it is essential to evaluate different treatments and their cost-effectiveness, especially with the aging population in Singapore.
The management of knee pain can be multidimensional. Conservative management such as weight reduction, physical therapy, or pharmaceuticals, injections, and surgical intervention can be done depending on the severity of the knee pain and the underlying cause. The main goal should be to reduce pain and improve function while preventing further damage to the knee joint.
With an aging population, there is an increased prevalence of knee pain, and its potential impact on public health has raised concerns over effective management of this disabling condition. Knee pain can be caused by a multitude of reasons, with the commonly occurring pain from degenerative diseases. Other causes include trauma, acute injury, internal derangement, or other diseases such as rheumatoid arthritis.
Old age catches up with most of us, and often, the part of our body that gives way first is our knees. Over time, there has been a rising incidence of knee pain among Singaporeans, and it is now considered a frequent symptom in the adult knee pain Singapore population. Knee pain can be disabling, and it is one of the most common musculoskeletal problems that bring people to their knee pain specialist. It is often a chronic problem and can occur at any age.
Understanding Knee Pain
The medial and lateral collateral ligaments prevent the knee from moving too much side to side. The cruciate ligaments cross over each other in the middle of the knee and help prevent the femur from moving too much forward or backward on the tibia. The other two ligaments are torn much more frequently than the cruciates. These are the medial and lateral menisci, which act as shock absorbers within the knee and provide some degree of cushioning between the bones. These articulating surfaces are lined by the articular cartilage, which is the substance that is damaged or worn in the majority of knee problem instances. It is through damage to this articular surface, usually to a specific area of it, that the pain is caused. Articular cartilage has poor healing ability due to its lack of blood supply and may not repair adequately.
Understanding knee pain requires an understanding of the anatomy of the knee. The knee is the largest joint in the body and involves articulation between three bones: the femur, tibia, and patella. There are four main ligaments which help stabilize the knee.
Importance of Effective Management
Knee pain is a very common complaint in today’s society that affects people of all ages. Whether the result of an injury or a chronic condition such as arthritis, knee pain can interfere with everyday activities and quality of life. Knee pain can arise in any of the bony structures of the knee joint, the kneecap, or the ligaments and cartilage of the knee. It is a complex structure consisting of three compartments: the femur-tibial, the femur-patella, and the patella-tibial. Any of these can be affected by disease or injury, which can result in pain. Because of the weight-bearing function of the knee, knee pain is often made worse by weight-bearing activities such as walking, running, standing, or crouching. A proper understanding of the cause and nature of the pain is important for the physician to decide upon the proper course of treatment. This, in turn, is essential for effective management.
Non-Surgical Approaches
When he started treating knee injury patients a few years ago, he carried that philosophy a step further by using athletes and came to realize that for most knee pain, even after an injury, the results were the same: joint pain from worn meniscus and cartilage. It is a rare patient that gets instant relief from keyhole meniscus or cartilage surgery, so the best course of action is to first try and maintain the joint and its function with simple physiotherapy and exercise. Once the joint starts to show signs of age and pain, there is a window of opportunity to target the symptoms and maintain joint function with specific treatment for the pain. This is the stage where the patient can achieve the best symptomatic relief and often can delay the onset of arthritis and further degeneration. This has been very popular with the senior age group who wish to remain active. Usually, the damaged meniscus tears further and osteoarthritis reaches an irreversible stage. Therefore, there are limited possibilities for certain groups of patients, such as middle-aged men with isolated meniscus tears.
Physical Therapy and Rehabilitation
Another common method of exercise therapy is hydrotherapy, or the use of pool-based exercise. Immersion in warm water has several physical effects on the body. Warmth causes vasodilation, which increases blood flow to injured tissues and aids in the relaxation of muscles. Immersion in water results in hydrostatic pressure that helps to reduce peripheral edema through compression. The buoyancy provided by immersion unloads the weight bearing placed on the knee joint and allows for movement with minimal impact. This is particularly beneficial for individuals with acute knee injuries who are unable to take any weight through their knee to undertake exercise. High impact or strenuous activity that is normally too painful for an individual may be possible with little discomfort underwater. A recent randomized control trial has concluded that pool-based exercise is more beneficial than gym-based activity for individuals with knee osteoarthritis.
A physiotherapist will assist in the identification of muscle weakness and provide appropriate exercise therapy to strengthen the affected muscles. A common method of increasing muscle strength is resistance training using weights or resistance bands. Studies have shown that increased quadriceps strength is directly correlated with reduction of pain and increased knee function in persons with knee osteoarthritis.
The purpose of physical therapy in knee pain management is to increase strength and flexibility of the muscles that support the knee joint. The knee serves as a vital hinge that allows the legs to extend and flex. The ability of the knee to function in this manner is largely dependent on the muscles that support it. The quadriceps, hamstrings, and leg muscles are responsible for stabilizing and moving the knee in various planes. Weakness or imbalance in the strength of any of these muscle groups can lead to poor knee function and pain. The muscles in the hip and lower leg also play a role in knee function.
Medications for Pain Relief
One of the most frequent alternatives to minimize knee pain is the consumption of medication. The choice of drug should be tailored to the medical and knee condition of the patient. Simple analgesics like paracetamol and certain anti-inflammatory tablets (e.g. ibuprofen) have been found to be beneficial for several arthritic conditions. However, some patients may not achieve relief of pain using these drugs. Patients with a history of peptic ulceration disease, suffering from another condition that requires antiplatelet treatment, and elderly patients are at risk of developing adverse effects using this group of drugs. A recent meta-analysis found that NSAIDs cause a significantly higher risk of serious upper gastrointestinal complications, with complicated peptic ulcer, obstructing or bleeding ulcers, and deaths, and this pattern is broadly similar for the different NSAIDs. Therefore, it is recommended to give the lowest effective NSAID or coxib at standard dose. If there are also other risk factors for ulcer complications (e.g. corticosteroid use, a past history of ulcer or upper GI bleeding), it is recommended to add a PPI. Besides that, NSAIDs will impair renal function, particularly in the elderly, and reduce the effect of diuretics and antihypertensive drugs. Therefore, whenever possible, the use of NSAIDs should be limited to the lowest dose for the shortest possible time, and monitoring for the signs and symptoms of adverse effects should be made routinely.
Surgical Options
Total knee arthroplasty is a well-established and successful procedure in relieving pain, correcting leg deformity, and increasing function and is considered to be one of the most valuable surgeries in modern medicine. It involves resurfacing the damaged knee with metal and polyethylene components to replicate the knee joint. The Haga Total Knee System is a recent local design that is less costly with satisfactory results. Patients are usually elderly and have multiple medical problems. They have generally exhausted all other forms of treatment and the severity of the disease impairs their quality of life. Though results are less successful in younger patients, many are also having the procedure due to disabling disease. Over time, with advances in technology and an increase in public demand, it is likely that TKA will become a more common procedure compared to the present.
Arthroscopic Procedures
ACL reconstruction surgery is indicated for young, active individuals with an ACL tear, mostly due to the high risk of developing meniscus and/or articular cartilage damage. The goal of the surgery is to prevent further damage to the knee and meniscus and reduce the risk of developing degenerative joint disease.
The primary symptoms of an ACL tear are swelling, instability, or a subjective feeling that the knee may give way, and an inability to participate in regular physical activities. A diagnosis can usually be confirmed with McMurray’s test and/or a positive finding on the Lachman and/or Anterior Drawer tests.
Treatment in older, less active patients may involve a specific exercise program to strengthen the surrounding knee musculature. However, for active people involved in sports and activities requiring pivoting, turning, or hard cutting, a torn ACL will cause ongoing instability problems in the knee and predispose the knee to further injury and joint damage. This will, in turn, lead to an increased risk of developing degenerative joint disease in the knee, and ultimately the result is a higher likelihood of developing osteoarthritis of the knee.
ACL reconstruction is a common arthroscopic knee surgery and is the procedure of rebuilding a torn anterior cruciate ligament. The ACL can be torn as a result of a sudden twisting or change in direction, usually when moving at speed. This often occurs during a soccer or rugby game and is becoming more frequently seen in skiers and netball players. An injured ACL will often cause the knee to give way during activity and usually lead to further damage of the meniscus cartilage.
Arthroscopic surgery, also known as keyhole surgery, is the procedure of visualizing, diagnosing, and treating joint problems. This technique involves making a small incision in the patient’s body and then using pencil-sized instruments containing a small lens and lighting system to magnify and illuminate the structures inside the joint.
Total Knee Replacement
Total knee replacement has been long established as a victorious treatment for knee arthritis. It has offered end-stage knee arthritis sufferers with significant improvement in pain, satisfaction, function, and quality of life. The surgery is proposed to relieve pain and obtain near-normal function with an artificial joint and has done so in many cases. Due to its proven success on multiple occasions, it is assessed to be cost-effective. This enquires the fact that there are substantial improvements in quality-adjusted life years after the surgery. If one is the appropriate candidate for the surgery, it is almost certainly going to benefit the outlook on the way of living. Patients will get further satisfaction in the overall improvement of their way of living.
Total knee replacement is now the final and only option for knee arthritis, and its valuable benefits are clearly noticeable among sufferers. This is seen in the increased incidence of surgeries conducted worldwide. The number of surgeries conducted is increasing yearly. From 1997 to 2002, there was an increase of 87 percent in the rate of total knee replacements – from 41 to 76 per 10,000 people. It is predicted that more people are to opt for this surgery in the future as the older population is increasing. This procedure is irreversible and should only be accessed after all other possible options have been attempted. This includes all non-operative and operative treatments.
Integrative Therapies
However, a recent randomized controlled trial comparing acupuncture to sham acupuncture in patients with chronic knee pain did not show immediate significant improvement in pain or physical function. The authors noted that the small sample size of the study may have limited its validity and increased the possibility of type II error. Further research is needed to determine the effectiveness of acupuncture for knee pain and its mechanisms of action.
Electroacupuncture, which involves applying a pulsating electrical current to acupuncture needles, has been found to produce changes in the central nervous system and increase the release of endorphins and enkephalins. These substances help reduce pain sensation. A recent study in Sichuan, China, found that electroacupuncture was more effective than traditional Chinese acupuncture or medication in treating knee pain. Patients in the electroacupuncture group experienced greater improvements in symptoms and functional ability, and their progression to surgery was slower. Electroacupuncture is also considered a safer alternative to NSAIDs as it does not harm the stomach lining or affect blood clotting.
Acupuncture is a component of traditional Chinese medicine that originated in China over 2500 years ago. It is based on the belief that health is determined by a balanced flow of life energy (qi), and imbalances lead to disease. Acupuncture aims to correct these imbalances by stimulating specific anatomical locations on or under the skin using various techniques.
Evidence suggests that traditional Chinese acupuncture may be beneficial for knee pain. A study conducted in Shanghai found that patients who received acupuncture reported reduced pain and stiffness compared to those who received minimal acupuncture. However, more rigorous clinical trials on acupuncture for knee pain are yet to be published. The most reliable evidence on the effectiveness of acupuncture for knee pain may come from studies on other types of chronic pain.
Acupuncture for Knee Pain
Despite all these positive findings, Western medicine has been slow in the past to incorporate acupuncture into mainstream care. However, its recent strong recommendations in treatment guidelines reflect an increasing acceptance of alternative therapies in the medical community. A US national survey on Americans’ use of CAM found that 8.2 million US adults had used acupuncture. This number no doubt has increased in recent years. With an Asian population of approximately 1.3 million in the UK, 6% of this total population are high-volume users of acupuncture, and on average, every UK citizen receives acupuncture two to three times a year from a demonstrated random survey. With increasing use and demand for acupuncture, it is likely it will become a standard treatment in knee pain management in the future.
Clinical practice guidelines recommend acupuncture as one of several non-drug approaches that may be helpful for clinicians managing patients with chronic low back pain, a similar pathology to chronic knee pain. These guidelines were based on a large-scale analysis of treatment modalities for chronic knee pain, which found the evidence for the use of acupuncture in treating knee pain to be conclusive. Acupuncture has also been found to be as effective as NSAIDs in relieving chronic knee pain and with fewer side effects. An interesting finding in this study was that patients felt their acupuncturist’s attitude towards them and the treatment had an effect on their pain relief. This may explain why in some trials, true acupuncture (puncturing skin) was more effective than sham acupuncture (using a device to give the patient the feeling of being punctured). Sham acupuncture, however, was still more effective than standard care techniques such as NSAIDs and strength training.
Acupuncture, a traditional Chinese medicine, is being used increasingly in the Western world for pain relief. It involves inserting hair-thin needles into specific parts of the body to unblock the flow of energy or Qi and to bring the body back to a state of balance. Western acupuncturists believe that acupuncture stimulates the nervous system and causes the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.
Herbal Remedies and Supplements
Herbal remedies and supplements offer an alternative treatment to pharmaceutical medications. This will be discussed later in another article.
This is important because some of the pharmaceutical pain and anti-inflammatory medications can have detrimental side effects for knee OA patients, especially for the elderly. For example, NSAIDs can irritate the stomach and could worsen pre-existing stomach ulcers. They can also impair kidney function, resulting in a gradual but potentially serious decline in renal health.
Herbal remedies and supplements are another widely used aspect of integrative medicine. So, for the knee pain sufferer, it makes sense to ask, “Do any herbal remedies or supplements work for my knee pain?” The answer is that it is quite likely. Many kinds of herbs, spices, and supplements have been shown to reduce some of the symptoms of knee OA. Some of these substances may also have fewer side effects than pharmaceutical medications and could represent a safer alternative.
