Understanding Knee Pain and How to Manage It in Singapore

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Musculoskeletal conditions, injury, and trauma are the common causes of knee pain. A rupture of one of the four Anterior Cruciate Ligament (ACL) is also a common cause of knee pain. This will be followed by swelling, pain, and inability to continue activity. A severe injury to the knee can result in bone fracture. People with osteoarthritis often develop knee pain. The most common symptoms are pain and swelling, and a decrease in knee motion. Treatment often helps with the pain and swelling, but the knee problems increase the chances of developing widespread osteoarthritis. Another common cause of ongoing pain is pes anserine bursitis. A bursa is a sac of fluid that allows smooth movement between two moving surfaces. This bursa is situated about 5cm below the knee joint on the inner aspect of the knee. This is over the tibia bone. The bursa will become inflamed from trauma or repetitive strain on the knee from bending or overuse. This is common in people with poor strength in their hamstrings and overweight people. The bursitis results in pain and swelling in the inner knee. Patella-femoral pain syndrome is another ongoing pain problem that is a common cause of knee pain in the young. This is basically pain surrounding the kneecap. A multitude of etiologies have been proposed for this problem, but essentially it’s from overuse of the knee. This is seen in sports people and is very common in females who play a lot of netball. The pain is often generalized and swelling is not uncommon. This is because the tip of the patella is rubbing on the underlying bone. This problem can lead to osteoarthritis later in life.

Causes of Knee Pain

One of the most common problems is an injury to the anterior cruciate ligament (ACL). The ACL connects the femur to the tibia. If it is sprained or torn, there will be pain and swelling in the knee, instability, and a buckling sensation. Another common ligament injury is to the meniscus. The meniscus is a rubbery, C-shaped disc that cushions your knee. Each knee has two menisci (plural of meniscus), one at the outer edge of the knee and one at the inner edge. This type of injury plagues many athletes and older people because it can occur from a simple twist of the knee.

The knee is the largest joint in your body and also one of the most complex. It is vital for so many movements that it is at risk for many types of injuries. This complexity also makes the knee vulnerable to other types of injuries. This can lead to an imbalance in the muscles and can result in added stress on the knee, causing more problems. Misalignment in the knee can also cause pain. If any part of the knee is not moving in its normal plane (either through injury or a structural problem), it can cause a wearing of the cartilage or a change in the pull of the muscles.

Common Symptoms of Knee Pain

Onset of pain can be sudden or gradual, and if the injury is a result of a specific impact it is possible that the knee can swell quite quickly with blood from the ruptured tissues, or from bleeding into the joint. This is known as haemarthrosis and should be assessed by a doctor.

Front of knee pain Symptoms: – Pain over the front of the knee and around the knee cap (patella) – Pain when walking up or down stairs, squatting, running, or using the knee for prolonged periods. – Pain subsides after stopping the activity which caused the pain. – Swelling of the knee may or may not occur. – Clicking or creaking sounds around the knee cap. – Weakness of the quadriceps muscles in the front of the thigh. – Descriptions of feeling the knee is giving way, or not being able to trust or support the knee can be common, with some people feeling the knee is about to give way on stairs or slopes. This may occur after activity involving bending of the knee or straight after a period of inactivity. It may wake people from sleep, particularly if the knee is straight or bent, and can be due to a tear in the cartilage. Any giving way, or a feeling of the knee not being able to support the body, is usually a sign of a mechanical problem within the knee and should not be ignored.

Pain in the knee is often mistakenly seen as a problem in itself rather than a symptom of a problem. The location of the pain in the knee can be a helpful clue in discovering the underlying problem:

Importance of Seeking Treatment

The same study also showed that increased physical activity is associated with a decreased risk in many health conditions. This leads to fewer doctor visits, less medication, and fewer medical problems in general. If your knee pain is stopping you from being active, you could be starting a snowball effect of health-related problems due to the inactivity and worsening of your overall health.

People who are less active due to knee pain will have more problems as they age. Studies have shown that people who are less active are not as healthy. “Many older adults do not know how frail they are until it’s too late,” said Jack Guralnik, M.D., Ph.D., University of Maryland School of Medicine. If you are active, that definitely does not mean that you won’t become frail, but being active is an indicator that helps maintain the state of health and the probability of becoming frail is much lower than those who are less active. A different study involving both women and men showed that the risk of functional limit was significantly lower among adults who were more physically active.

When you experience knee pain, it is important that you seek treatment from experienced professionals. Since knee pain can cause many complications to your daily life, traveling, work activities, and overall comfort, it is important that you get effective treatment. “All these things are linked to a person’s independence and their ability to function and stay active so they can continue to age successfully.” Linda Macphail PT, MS, GCS is an advanced clinician at the Brigham and Women’s Hospital in the Department of Rehabilitation Services, and also an instructor at the Harvard Medical School. With aging, comes the fact that you might have to give up certain things that you love to do. “We all have to give up certain activities because of aging, that’s a given. But, without that available choice to choose to age successfully, giving up things becomes a consequence rather than a choice.”

Non-Surgical Treatment Options

It is often possible to alleviate joint pain and stiffness through simple changes in your daily routine. A cane can be used in the hand opposite the affected leg to help reduce force through the knee joint. A single crutch is not recommended as it can actually increase the load on the knee. Shoes with cushioned insoles can help to reduce impact on the knee when walking. Using a brace can improve stability and reduce pain with certain activities, and assistive devices such as raised toilet seats or handrails can make it easier to carry out daily activities. Weight loss can be one of the most significant ways to alleviate knee pain. For every pound lost, there is a four-pound reduction in the load exerted on the knee for each step. Hence, weight loss can have a great effect on reducing pain and improving function in the arthritic knee.

Many different medications are used to treat knee pain, both oral and topical. Often patients with severe joint pain are recommended to take paracetamol or other NSAIDs. If these are ineffective or unsuitable, other pain medications such as weak opioids or injections of corticosteroids into the joint may be considered. Glucosamine and chondroitin are also commonly used and are intended to alleviate pain and maintain joint function. These are used for symptom relief rather than disease modification. Always consult with a healthcare professional before taking any medication as part of your treatment.

Physical Therapy and Exercise

Physical therapy (PT) is a widely researched and proven form of treatment for knee pain caused by osteoarthritis. A program of PT will be designed to address the specific functional limitations related to the OA diagnosis. Most people with arthritis are aware that exercise is an important and effective form of treatment. What is not commonly understood is the best form of exercise for their specific problem and the appropriate method for progressing to more difficult exercises. Because the muscles around the knee are often weakened and the range of motion is often limited, the best form of initial exercise is an isometric or static contraction of the quadriceps and hamstring muscles. This type of exercise causes very little joint irritation and can be performed in a sitting or lying position. The next step is to improve the strength and endurance of the muscles with isotonic exercises. This form of exercise is also beneficial to the knee joint and can be performed with a theraband, which is a tool commonly used in PT to provide resistance for strengthening exercises. PT will also utilize a very good form of exercise called aquatic therapy. This consists of various exercises performed underwater in a swimming pool. The advantage of aquatic therapy is that the buoyancy of water reduces the amount of stress placed on the joint, and the resistance of the water helps to build muscle strength. Overall, it is important for people with knee osteoarthritis to stay as physically active as possible while not exacerbating their pain. PT will encourage the use of aerobics machines or an elliptical machine to maintain cardiovascular fitness without applying excessive amounts of stress to the knee joint. In certain rare cases of severe joint destruction, PT may recommend the use of a custom-designed knee brace to offload a portion of the joint. This can only be done by reducing the activity level while wearing the brace. Although it is not a huge benefit to the overall health of the joint, it may be beneficial in allowing a person to delay a total knee replacement.

Medications for Pain Relief

An agent designed to help manage OA knee pain is diacerein – a symptomatic slow-acting drug for osteoarthritis (SYSADOA). This class of agents requires a duration of several weeks before it decreases pain and may also improve the underlying structural pathology of the joint.

NSAIDs – both oral and topical – are one of the most commonly recommended medications for knee pain. They are a top-line treatment in managing pain and inflammation caused by knee and hip OA and have been effective in keeping many patients off the operating table. In 2010, the Osteoarthritis Research Society International (OARSI) recommended that the international medical community make topical NSAIDs a first-line treatment for patients with knee or hip OA. This advice was based on research that indicated the efficacy of such treatment and the fact that the risk of certain side effects is smaller than with oral NSAIDs. Possible side effects of NSAIDs include stomach irritation, ulceration or bleeding, allergic reactions, and liver or kidney problems.

– Analgesics: these are pain-relieving drugs and include paracetamol and the many different types of non-steroidal anti-inflammatory drugs (NSAIDs). – Topical agents: cream, gel, and ointments over the counter and prescription.

There are many different medications for pain relief that can be used to control knee pain. These drugs can be useful in controlling pain and decreasing inflammation that is associated with most forms of knee pain. Remember it is very important that you talk to your doctor before starting any medications and make sure that they are safe for you to take. It is very important to use this medication sparingly, never exceed the recommended dosage, and only use this medication as long as it is necessary. Overuse of some analgesic medications can cause kidney damage and possible failure. Different medications include:

Lifestyle Modifications for Knee Pain Management

Regular exercise – Although it contradicts the idea of rest, regular exercise is important to maintain functioning muscle strength. This can be achieved by simply walking for 5-10 minutes or more if possible, provided it is not causing further pain or discomfort. Swimming is a good form of exercise as this places relatively no weight on the joint.

Adequate rest – By getting 8-9 hours of sleep each night alongside short naps during the day, the body is able to repair and recuperate from any stresses or strains that have been placed on it. The use of an electric blanket or warm bath at night can help relax the muscles and ease any aches, providing a more restful sleep.

Maintain a healthy weight – By maintaining a healthy weight, the amount of force exerted on the knee joint is greatly reduced. This is because for every pound lost, it is the equivalent of 4 pounds of pressure taken off the knee when walking. This is based upon the fact that when walking, each step creates a pressure of 1.5 times your body weight.

Surgical Treatment Options

Arthroscopic Surgery

The second arthroscopic technique is lavage and injection of intra-articular substances. A similar technique is used to debridement, the only difference being the type of medicine used; for example some surgeons will use corticosteroid for its long term effect on symptoms, opting to only use it for patients with a high level of pain and disability. Another medicine used is hyaluronic acid, which is a treatment for patients who have mild and moderate osteoarthritis. This treatment will help to improve joint movement and reduce pain, and although it is very effective, the cost is relatively high. Both lavage and injection of intra-articular substances will last between 20 to 30 minutes and the recovery time is slightly less than that of debridement.

Debridement, or the removal of debris and damaged tissue, is a technique used to clean the knee joint. At Singapore General Hospital, this procedure is performed using arthroscopy, which is a procedure where a small telescopic camera is inserted into the joint. The video image is then viewed on a TV monitor, allowing the surgeon to investigate the knee joint fully. This is done through two or three small keyholes around the knee joint. An additional keyhole may be made at the back of the joint to remove any swelling. The inside of the joint is then cleaned using a variety of instruments before the washing and suction of the joint completes the procedure, lasting between 30 to 60 minutes. Arthroscopy can also be used to detect and treat knee conditions; for example recovery is quick and relatively pain free and will usually allow for same day discharge. Overall, arthroscopic debridement has been shown to be an effective treatment for osteoarthritis of the knee and will help to improve symptoms and functional level over time.

Total Knee Replacement

TKR is most indicated in older patients with severe pain and stiffness, or those with significant functional or mobility loss. Conversely, patients with minimal symptoms, younger patients, and those with medical co-morbidities limiting their life expectancy should avoid surgery. The most common indication is severe osteoarthritis; however, it may be performed in other conditions such as rheumatoid arthritis and post-traumatic arthritis. Patients with a significant deformity or limb malalignment are well suited to TKR as correction of these issues can be incorporated into the surgical technique. The decision to proceed with surgery should be a shared decision made between the patient and their surgeon.

Total knee replacement (TKR) has been one of the most successful interventions in the management of chronic joint pain. It has been demonstrated to alleviate pain, improve function, and quality of life. More than 160,000 TKRs are currently performed each year in England and Wales with a success rate of over 90% at 10 years from the National Joint Registry. The role of TKR has expanded with more patients undergoing surgery at a younger age. The key to a successful TKR is establishing the correct indications and realistic patient expectations.

Partial Knee Replacement

Partial knee replacement is a surgical procedure which involves resurfacing and replacement of only the damaged compartment of the knee. The knee comprises of three compartments, medial (inside), lateral (outside), and patellofemoral (front). In the past, suitable candidates for partial knee replacement were scarce as the surgical procedures and implants were in its developmental stages. Hence, total knee replacement was the gold standard in treating painful and arthritic knees. However, due to an increase in life expectancies and more active lifestyles, there are an increasing number of patients who develop isolated arthritis in any one of the three compartments. Also, with advancement in technology and better understanding of the knee kinematics, partial knee replacement is now a proven and tested procedure with excellent long-term results. Patients who undergo successful partial knee replacement do well in performing activities that demand a high degree of function and mobility. These include but are not limited to golf, cycling, swimming, yoga, and competitive sports such as basketball and soccer. When compared to total knee replacement, partial knee replacement is a less invasive procedure and hence the risks and complications are significantly lower. Implant longevity has always been a concern with total joint replacements. The common belief is that the younger the patient is, the longer the implant has to last. Hence, with patients developing isolated arthritis at a younger age, partial knee replacement provides an attractive solution. Also, in the event of a failed partial knee replacement, the conversion of a partial knee replacement to a total knee replacement is a relatively simple procedure as the implants in the total knee replacement often mirror that of the partial knee replacement.

Post-Treatment Rehabilitation and Recovery

Rehabilitation begins soon after the surgery and will continue for several months. The primary goal is to return to your normal activities during the day without pain or swelling. The conditioning program is designed to help you attain this goal. It is important to follow the specific instructions your doctor gives you. Rehabilitation programs for ACL injuries have changed over the years. “Start low, go slow” is a good rule of thumb during the rehabilitation of your knee. It is important to work with your doctor and therapist to find the right balance of rest and rehabilitation. Many athletes in the past have had complications because they tried to advance their rehabilitation too quickly. Adherence to this principle will suppress long-term joint degeneration and will foster a positive attitude towards rehabilitation. A progression can be seen in the program that follows. This is only a guideline and the program should be changed to fit your specific needs, which should be determined by you and your therapist. An example of an ACL ruptured knee rehabilitation program developed for a National Level Footballer can be seen in the next section. During this program and the rehabilitation progression, there is something that we must avoid and is specific to the type of surgery performed, which is an ACL reconstruction.

Rehabilitation Exercises and Therapies

Rehabilitation is an essential part of successful knee pain treatment Singapore for individuals with knee pain or injuries. Various therapy methods can help with the faster recovery and decrease the risk of further injury. Specific exercises and activities build the strength of the muscles that support the knee joint. Strong muscles help the knee absorb shock more efficiently and keep the knee stable during athletic activities. It’s best to discuss exercise and physical activity with a doctor because doing the wrong exercise can cause further harm to the knee. A certified athletic trainer, physical therapist or other healthcare professional can help develop an exercise program that fits individual patient needs. They can provide intensive instruction and supervise a patient’s exercise program. Water exercises, which are gentle on the knee, can be more effective than land-based exercises. Some people can benefit from wearing a stabilizing brace when resuming certain activities. The decision should be discussed with a doctor or physical therapist. A brace can help prevent re-injury by providing additional support to the knee. In severe cases, especially if the patient has multiple knee injuries or an injury to the knee’s structure, a clinician may recommend surgery to reconstruct the knee. Physical therapy after surgery has many similarities to rehabilitation for a non-surgical knee treatment, although there are some different exercises and the therapy is often longer and more intense.

Pain Management Strategies

There are numerous medications available to treat joint pain in the knees. Over-the-counter painkillers such as acetaminophen and ibuprofen help with pain and swelling, whereas products such as glucosamine and chondroitin are thought to help lubricate the joints and stimulate the growth of new cartilage. For the most severe cases, there are stronger, prescription pain relievers and anti-inflammatory drugs as well as steroid injections. All of these options should be discussed with your doctor. He may have samples for you to try before you commit to buying anything.

Excess weight can exacerbate knee pain. This is because your knee is a weight-bearing joint, and the more stress that is put on it, the more pain you will feel. Indeed, every pound of weight adds four pounds of pressure on the knee joint. Therefore, losing weight is probably the single most important thing you can do to reduce knee pain. This does not mean you have to engage in vigorous exercise, as this is often difficult for those who suffer from joint pain. Basically, it is an issue of expended calories. When you decrease your food intake, you will lose weight. This in turn will lead to less pain in the knees.

Anyone can be affected by knee pain, regardless of age. However, it is typically more problematic for the elderly as joint pain is directly related to the aging process. Fortunately, there are ways to manage the pain of aching joints, regardless of your age or whether the pain is the result of arthritis or an injury.

Tips for a Successful Recovery

Physiotherapy can be of benefit to fast track your recovery. Even one or two sessions with a physiotherapist to start with can help tailor exercises to your specific knee problem. Exercises should aim to regain full range of motion and strength of the injured knee, with a focus on exercises with good functional outcome and minimum aggravation to other joints. This is a contrast to the start of the rehabilitation, where the main focus is to reduce swelling and regain normal gait pattern.

An appointed surgeon may have repaired your ACL and meniscus from your knee injury. For the repair to be successful in the long term, the knee must not develop new injuries as it is recovering. The recovery must also prioritize the prevention of osteoarthritis in the injured knee. Patience and commitment are crucial to maximize the quality of the recovery, thus ensuring the prevention of new injuries and osteoarthritis of the knee. ACPN Tay Eng Hui recommends a period of 3-6 months of focused rehabilitation post knee surgery. This period requires a systematic and steady progression of exercises and strengthening to reload the injured tissues, while ensuring that the non-injured areas do not become overloaded in this process.

A successful recovery from a knee injury or knee surgery is crucial in the overall management of knee pain. The quality of the recovery can affect the progression of – or even alleviate – the initial knee problem. There are several ways to ensure your recovery is a success.

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