Non-Surgical Knee Pain Treatment

Knee Pain
Knee pain can arise from various sources in and around the knee joint, such as tendons, ligaments, nerves and fat pads. Sometimes, it may be referred or radiation pain originating from problems higher up, such as the lower spine or the hips. Often with longstanding pain, there may be multiple causes including central sensitisation (pain “imprinted” on the brain), and therefore requires a careful history, examination and tests to ascertain the various pain generators, thereby to address all of them in order to deliver the best pain relief and restoration of function possible.
Perhaps the best known cause of knee pain is OsteoArthritis (OA), though it is not the most common cause, nor seldom is it the only pain generator.  It is a degenerative joint disease characterised by the wearing down of the knee cartilage over time, resulting in pain, stiffness, and difficulty with movement.  As with any treatment of knee pain, the goal is primarily to reduce pain, improve mobility and function; and, if possible, to retard the degeneration.  The specific treatment approach will depend on the severity of the OA and the specific needs and preferences of the patient.

Non-surgical treatment options for knee OA include:

  1. Lifestyle changes: For those who are overweight, weight loss by even 2-3 kg has been shown to reduce the load on the knees enough to significantly reduce pain. Switching away from weight-bearing exercises which exacerbate pain such as running or jumping, to activities like biking, swimming or taichi, can also help.
  2. Physical therapy: Physical therapy geared towards improving quadriceps (anterior thighs) and hip external rotators (deep buttocks) strength can reduce pain, and at the same time, improve mobility and stability. Exercises may include range-of-motion exercises, stretching, and strengthening exercises.  A physiotherapist is best equipped to guide you through this recovery journey.
  3. Assistive devices: Using a cane, crutches, or a knee brace can help reduce the load on the affected knee and improve mobility. Understandably, most people would prefer this to be a temporary measure.
  4. Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen or Etoricoxib, can help reduce pain and inflammation. Other medications, such as Paracetamol and Tramadol, may also be used to manage pain. Some of these medications can have significant side-effects if used long-term, especially in the more elderly with cardiovascular comorbidities.  Judicious use is therefore advisable.
  5. Injections: Corticosteroid injections into the joint can reduce inflammation and pain, especially if the joint is swollen. Viscosupplementation, which involves injecting a lubricating gel (hyaluronic acid) into a mild-to-moderately degenerative knee joint, can reduce pain and improve mobility for 6-12 months on average.

If non-surgical treatments are not effective, surgery may be considered:

  1. Arthroscopy: This is a minimally invasive procedure whereby a small camera and other instruments are inserted into the knee joint through several small skin incisions to diagnose and treat problems in the joint.
  2. Osteotomy: This procedure involves cutting and reshaping the bone to improve the alignment of the joint and relieve pressure on the damaged area.
  3. Knee replacement: During this procedure, the damaged parts of the knee are removed and replaced with artificial components. Knee replacement surgery can be performed using traditional open surgery or minimally invasive techniques.
There are several emerging minimally invasive options for treating knee pain. These options may be appropriate for people who have mild to moderate OA and are looking for a less invasive alternative to knee replacement surgery, or who may be medically unsuitable for surgery due to multiple comorbidities:
  1. One option is neuroablation, which seeks to reduce pain by targeting and blocking sensory nerves that transmit pain signals. This can be achieved through either radiofrequency ablation, which involves using radiofrequency heat energy to destroy the nerves; or cryoablation, which freezes the nerve to numb it.  Either procedure can yield durable pain relief lasting 6 months to a year, or even longer; and can be very safely repeated should the pain recur.  The advantage of cryoablation over RF ablation is the lower rate of neuroma formation (which can cause phantom pain), as the nerve is not destroyed.
  2. Another emerging minimally invasive treatment for repair of degenerative knee tendons, ligaments and cartilage involve the injection of platelet-rich plasma (PRP) which contain growth factors to stimulate the body’s natural healing process; or mesenchymal stem cells (MSC) derived from bone marrow and fat tissue to promote regeneration of damaged tissue.
In considering any treatment for your knee pain, the most important first step is to consult your doctor to determine the pain generator(s), followed by establishing your treatment goals (pain relief, improve function/mobility), before choosing the type of treatment most suited to your disease severity and comorbidities (if any), and what you are comfortable with. It may not be a dramatic success at first go, and it may take a process or a combination of therapeutic options to eventually achieve your goal.

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