Knee pain remains the most common musculoskeletal problem in the world and affects large numbers of people. The most recent data from the American Academy of Orthopaedic Surgeons states that four million aged Americans are living with a total knee replacement, with this figure expected to rise to 11 million by 2030. Simple step pain affects one in five aged people, whereas disability from knee pain affects one in ten. There are numerous causes for knee pain, with the most prevalent being osteoarthritis, a degenerative joint disease. Other causes include ligament, cartilage, or meniscus injuries, problems that are frequently sports-related. Non-traumatic causes include overuse syndromes, osteonecrosis, and referred pain. During the past ten years, there has been a great expansion of knowledge regarding the causes of knee pain and this has influenced treatment. Occurrence of knee pain peaks in the older adolescent years, and affects one in three people over 45 years of age. By this time, nearly everyone will have experienced an episode of knee pain. It is a common cause of lost time from work and physical inactivity, often signaling the end to an active lifestyle. People attempt to alleviate the pain by reducing activity, muscle strengthening, and weight reduction. In the past, specific events or structural abnormalities were believed to be the cause of knee pain. This led to the erroneous treatment of symptoms without addressing the underlying cause, and a large number of unnecessary surgical procedures. The more recent shift in focus from surgical to conservative treatment is based on the premise that the knee symptoms are not necessarily related to structural damage.
Lifestyle Factors Affecting Knee Pain
Exercise and physical activity Increased physical activity and exercise have been recommended for people with knee pain and osteoarthritis as it is associated with a lower risk of developing knee osteoarthritis. Although there is no definitive evidence that exercise leads to the development of knee osteoarthritis in people without a previous knee injury, it makes sense that high impact sport, competitive sports, and heavy physical work could cause damage to the joint. This is particularly relevant to younger people who have sustained a knee injury and are at higher risk of developing knee osteoarthritis later in life in the injured joint. So what about those people with knee pain who play sport and exercise? Is it safe for them? Can exercise cause harm to their joint? What type of exercise is recommended? Answering these questions is not so simple. The benefits of exercise for general health and well-being are well known. Unfortunately, some people in our society have become so sedentary that they fail to achieve the minimal level of physical activity to attain health benefits. It can be difficult to convince people to undertake exercise if they are experiencing pain. High impact activities and sports should be discouraged in those with known knee osteoarthritis. These activities have been shown to increase the rate of progression of knee osteoarthritis and increase the risk of functional decline and disability. However, exercise and physical activity in the form of low impact aerobic exercise, strength, and resistance training is safe and is actually recommended for the management of knee pain and knee osteoarthritis. A well-rounded exercise program is essential in managing knee pain and has many benefits for the knee joint and the person as a whole.
Weight management Being overweight is one of the greatest predictors of knee osteoarthritis. We put extra stress on our weight-bearing joints (hips and knees) for every extra pound of body weight. It is estimated that every additional pound of body weight increases the amount of force on the knee by three to four pounds. The combination of mechanical factors and the presence of inflammatory factors released from the fat tissue creates a perfect environment for the development of knee osteoarthritis in those who are overweight. Studies have shown that significant weight loss can reduce pain and disability and improve function in people with knee osteoarthritis. Weight loss is a complex and chronic issue in our society, with many misconceptions as to the cause of obesity and how it should be managed. Hopefully this can simplify the complexities of weight management and provide some guidance for those who are ready to make a change.
Weight Management
Weight management is an essential aspect of knee osteoarthritis. The relationship between obesity and knee osteoarthritis is a positive dose-response relationship: the heavier the person, the greater the risk of knee osteoarthritis. One pound of body weight translates into three pounds of force on the knee and up to six times the body weight force on the knee while climbing up and down stairs. Weight loss is one of the most significant ways of reducing functional limitations in people who already have knee osteoarthritis. A considerable weight loss of 11 pounds or more over a 10-year period is associated with a 50% reduction in the risk of knee osteoarthritis. Weight loss not only reduces the incidence and prevalence but also reduces the progression of the disease. Weight loss is a cost-effective way of helping people with knee osteoarthritis improve mobility and enhance quality of life. Weight management is a crucial way of preventing the occurrence and worsening of knee osteoarthritis. By maintaining an ideal body weight throughout life, joint overloading and injury can be prevented. This is because the force done on the knee joint escalates with increasing BMI: the risk of a person with a BMI greater than 25 developing knee osteoarthritis is 2.7 times that of a person with a BMI less than 25.
Exercise and Physical Activity
A randomized controlled trial in older adults with symptomatic osteoarthritis has shown significant improvement in physical function through participation in a combined program of aerobic, resistance, and flexibility exercises. Similar studies have demonstrated the safety and efficacy of land-based and water-based exercise programs for individuals with knee osteoarthritis. The general consensus is that participation in regular moderate-intensity exercise is beneficial for those with knee osteoarthritis and is unlikely to result in increased damage to the joint.
Similar benefits have been shown in previous studies exploring the effects of physical activity on arthritis, indicating that it would be wrong to single out knee osteoarthritis as a special case in which physical activity is harmful. Inactivity caused by avoidance of weight-bearing on the affected limbs and fear of eliciting further pain contributes to muscle atrophy and loss of strength, ultimately exacerbating disease and functional impairment. Regular physical activity can help to prevent these changes from occurring.
Despite fears, regular physical activity does not worsen knee pain and has beneficial effects on mobility and function. A twelve-month prospective study investigated associations between differing patterns of physical activity and functional ability in subjects with knee pain. Both men and women who took up regular walking or stair climbing showed significant improvements in functional ability. In those who took up stair climbing, the benefits were dose-dependent, with those climbing stairs more than five times a day showing the greatest improvement. In contrast, for those who reduced their level of stair climbing, functional ability deteriorated, highlighting the importance of maintaining activity levels.
Nutrition and Diet
Unique strategies from different individuals or groups may come into play with nutrition and diet. There is more than one route to a healthy, balanced diet; and there is more than one way to achieve weight loss. Discussing your diet and weight loss strategy with a dietitian, view it in the light of your current knee symptoms and OA severity, and explore how it may fit in with your overall management plan. Although an individual strategy may vary, dietitians and health professionals have provided some general suggestions for weight loss (and therefore knee pain reduction) which includes the following.
It is important to adopt a healthy and balanced diet. Being overweight causes excessive loading and strain on the knee – a negative for existing knee pain, and a recipe for increasing the risk of future problems. A high calorie diet may also lead to systemic inflammation, described earlier as detrimental to knee pain. Consuming an anti-inflammatory diet (such as avoiding processed and high-fat foods, and eating plenty of fruits, vegetables and whole grains) has even been suggested as one way to combat knee OA itself. However, current evidence in this field is limited, and so no strong recommendations can be made.
Supportive Care Approaches
The primary approach in managing knee pain is to maintain a healthy and active lifestyle. This includes achieving an ideal body weight, engaging in regular exercise to strengthen the muscles that support the knee, and making sure to exercise in moderation. It is also important to avoid too much stress on the knee and a reevaluation of the exercise program can be in order. That may mean trading a high-impact activity for a low-impact one – such as biking, swimming, or an elliptical trainer. “It’s also important to try to avoid too much sudden change, like too much intensity increase or change of the playing surface,” Dr. Kittleson says. “These are all common ways that people set themselves up for an injury.” Finally, it’s important to regularly stretch the muscles in the front and back of the thigh (quadriceps and hamstrings) to help optimize the knee’s range of motion. When these supportive measures are not effective, or in the presence of significant arthritis, certain medical treatments may be considered. Simple pain relievers such as Tylenol or anti-inflammatories like Ibuprofen or Aspirin can be helpful. Topical agents containing menthol or NSAIDs are options particularly for those who should avoid oral medications. If the arthritis is more significant, injections of a synthetic joint lubricant (hyaluronic acid) or a corticosteroid can be considered, and have been shown in studies to have good efficacy for pain relief and improved function.
Medications and Pain Management
Medications for knee pain patients Most patients with knee effusion and an inflammatory arthritis can benefit from the use of NSAIDs or selective COX-2 inhibitors. They effectively reduce the symptoms of pain and stiffness. Intra-articular joint injection with steroids is commonly done in a treatment procedure. It effectively provides pain relief over several weeks to months. Hyaluronic acid injection into the joint can effectively increase the viscosity of the synovial fluid and provide better lubrication and shock absorbing qualities to the joint. This allows regression of symptoms with possible long-term effects lasting six months to a year. It is a treatment procedure that can be repeated. However, the cost-effectiveness of the latter two treatments has been questioned in recent literature. This is especially so since there are alternative treatment procedures available. An example would be the use of glucosamine supplements. Glucosamine is an amino sugar that is believed to aid in building up the proteins that make up articular cartilage and synovial fluid. Studies of its effectiveness have been mixed. A recent multicentre, randomized, double-blind trial had shown that there was no evidence that glucosamine has a specific beneficial effect for patients with osteoarthritis of the knee when compared with placebo. The alternative treatment would be less risky and costly in the form of simple oral analgesics. This would suffice in mild cases of knee pain. However, for moderate to severe cases of knee pain, the use of oral opioid analgesics should be the last option due to its potential adverse effects and habit-forming properties.
Physical Therapy and Rehabilitation
Patients who have sustained knee injuries or have undergone a specific surgical procedure may have to participate in a rehabilitation program that is specific to that intervention. For example, a patient who has undergone an anterior cruciate ligament (ACL) reconstruction will do rehabilitation aimed at returning to an active lifestyle, as well as a progression of exercises and activities to safely return to desired sports. This patient would start with range of motion and strengthening exercises of the quadriceps and hamstring muscles and do agility training before being cleared to fully return to competitive sports. Step-down management of select osteoarthritis patients who are choosing to undergo total knee replacement may also benefit from a specialized program. Full recovery from knee pain is both realistic and achievable, and is best accomplished after a thorough rehabilitation program.
Rehabilitation therapy is another key element in the management of knee pain, helping to increase muscle strength and flexibility. A physiatrist is educated in various rehabilitation approaches to address functional limitations associated with knee pain. These may include modalities such as therapeutic ultrasound and iontophoresis, manual therapy techniques and instruction in specific exercises, such as aquatic therapy or tai chi. Physical and occupational therapists can also provide instruction in the aforementioned modalities and exercises.
It is important to participate in regular physical activity in order to fend off knee pain and strengthen the muscles that support the knee. Maintaining a healthy weight is also crucial in preventing and managing knee pain, as excess body weight increases stress on the knee joints. Both muscle strengthening and weight management can be achieved through an individualized exercise program that is developed with the help of a physical therapist. This exercise program can become part of a comprehensive knee pain management strategy, incorporating the use of medication and other non-surgical approaches.
Assistive Devices and Orthotics
Bracing is another common management strategy for knee OA. There are many types of braces available that are used for a number of different knee conditions. These include simple sleeves providing compression and warmth to unloading braces designed to shift load away from the affected part of the knee to its healthier part. A recent systematic review by Beaudreuil et al. concluded that bracing is an effective symptom-relieving strategy for medial knee OA. Unloading braces combined with an appropriate exercise program aimed at correcting functional biomechanical abnormalities may be able to slow disease progression by reducing overloading on the affected part of the knee. It is important that the patient seeks advice from a health professional with knowledge on bracing to determine the most appropriate type of brace for their condition.
There are both advantages and disadvantages to using a cane or a walker. A cane typically reduces the load on the affected limb and knee joint. It also provides an increased level of stability. Walkers provide even more stability and offloading of the affected limb. This can be especially beneficial for people with bilateral knee OA. Unfortunately, canes and walkers can become crutches. Individuals may become dependent on them and therefore walk even less than they would without them. Proper use of a cane or walker is a complex issue, and often the type and instructions on how to use them are not clear to the patient. He or she should consult a physical therapist or an occupational therapist for instructions on use and to determine the most appropriate type of cane or walker. Although findings from a study by Chang and Dillon demonstrated no inferior effects on pain, stiffness, and physical function between people using canes and those using walkers, the psychological implications of moving from a cane to a walker are very important. The use of an assistive device should be seen as a short-term/temporary measure.
When an individual is diagnosed with knee osteoarthritis (OA), the most common complaint is pain and stiffness. These symptoms can affect one’s ability to perform normal daily activities, including walking, climbing stairs, or rising from a chair. Often, this will lead to a history of decreasing physical fitness, muscle strength, and endurance. This, in turn, can lead to more pain and further damage to the knee joint. One negative outcome of this downward spiral is dependency on walking aids, including canes or walkers. Braces and other assistive device options may also come to mind.
Collaborating with Knee Pain Doctors in Singapore
In many cultures, there is an expectation that knee pain doctor Singapore are to be regarded as an authority figure; that their words are not to be questioned. This may create a difficult situation for a patient desiring to take an active role in their healthcare decision making. Ideally, you want to find a doctor who is open to discussion, is a good listener, is empathetic, and is willing to consider your treatment preferences. With the busy schedules that doctors have, it can be difficult to assess these traits in a short office visit. Therefore, it may be helpful to ask the staff at the doctor’s office about the doctor’s communication style and whether or not the doctor is willing to spend extra time with patients to discuss treatment options. If you or the doctor has a friend or colleague within the medical field, they may be able to provide information about the doctor’s reputation among other healthcare professionals. This can be valuable information to help you find the right doctor who is well respected by his/her peers.
In Singapore, you are fortunate to have access to many well-trained medical professionals. Unfortunately, this can complicate your search for the right knee pain doctor. Asking friends and family for a referral is a common way to start your search, but is this the best approach?
Finding a Knee Pain Specialist
Access to and the provider of a usual source of care varies from socioeconomic status and race. Patients between the ages of 18-54 and those with higher income were more likely to use a specific type of provider. Characteristics of a physician are another factor in the variability of care. Provider-specific disparities were seen in knee radiography where older physicians were less likely to order from 2 of 3 vignettes depicting medically inappropriate scenarios in comparison to younger physicians. This is important as inappropriate knee radiography can lead to further investigation or surgical procedures.
Deciding on the first doctor to see can be somewhat of a minefield. Studies have shown that the type of doctor and initial provider of care by a general or family practitioner may vary depending on patient factors such as severity, age, income, and insurance status. Then for specialist care, African Americans and Hispanics were less likely to see either an orthopedic surgeon or a rheumatologist in comparison to a visit to a non-specific health provider.
You will need to seek out a knee pain specialist for any serious knee pain. This may be an orthopedic surgeon, a rheumatologist, or a sports medicine physician. Your general practitioner will help you with this. The treatment that you receive will often depend on the special interests of the doctor.
Understanding Treatment Options
There are different types of treatments for different knee problems. Your knee pain specialist may suggest one or more of the following: Simple treatments are often the most effective in relieving pain and preventing further damage to your knee. These may involve losing weight or gaining muscle strength in your quadriceps to better support the knee. Exercises may improve the range of motion and flexibility of the knee, and a reduction in your activities that cause aggravation of your knee pain would be beneficial. Although these methods won’t “cure” your knee problem, they are essential in preventing further damage to your knee.
Your knee pain specialist will explain to you the different treatment options available for your knee condition, including an estimated timeframe, the risks and benefits of each treatment, and expected results. The amount of pain you are experiencing, your activity level, and whether or not you have developed arthritis will all be taken into consideration as your doctor decides what the best treatment option for you is.
Building a Supportive Doctor-Patient Relationship
The first step is to find a physician with whom you feel comfortable. Your doctor should respect your ability to make your own decisions and should be a willing partner in the decision-making process. Ideally, your doctor should be someone who follows an evidence-based practice, is well-informed about the latest treatment options, and respects your wish to consider those that may be provided by a different specialist.
Your relationship with your knee pain doctor can strongly affect your experience and satisfaction with medical care. Forming a good relationship, marked by effective communication and a high degree of trust, can be a challenge. However, it can be done, and doing so will work in your favor. This article looks at how you can build the best possible relationship with your knee pain doctor.
If you are a knee pain sufferer, the most important step to take is to work with a knee pain doctor in Singapore. Often, this entails finding an experienced specialist, learning about the treatment options available, and actively collaborating to decide on a treatment plan. All of this contributes to an ongoing doctor-patient relationship, one that has a powerful influence on treatment outcomes.
