Knee pain is a medical condition that has persisted for a very long time. With modern medical advances, conventional symptom treatments like physiotherapy, analgesia, NSAIDs, and hyaluronic acid injections are slowly being replaced or complemented by methods with direct and longer-lasting effects on the knee joint. Some of these treatments are also useful for prevention and treatment of progressive knee joint degeneration. As Singaporeans become more affluent and reject conventional treatments as a means, knee pain is likely to increase the focus to find new effective methods for treatment and prevention of degenerative knee conditions. This article reviews some of the areas of recent and new advances in knee pain treatment.
Traditional Knee Pain Treatment Methods
Finally, the use of corticosteroids can be of value in suppressing symptoms of more severe joint conditions such as rheumatoid arthritis and certain inflammatory disorders. Corticosteroids can be taken orally, but for knee conditions, they are often injected directly into the joint. This is known as intra-articular injection and can have dramatic effects in suppressing symptoms. However, there can be adverse effects and the effects are often temporary.
Glucosamine is a molecule that is thought to play a role in the repair of damaged joints and is commonly taken as a supplement by people suffering from degenerative joint disorders. Recent studies have shown it to be of some benefit in specific knee conditions, in particular osteoarthritis, and there is research indicating possible chondroprotective effects.
Medication has been the cornerstone of modern healthcare and plays a significant role in managing knee pain conditions. The most common form of medications used are simple analgesics such as paracetamol and NSAIDs (non-steroidal anti-inflammatory drugs). These can be useful to control pain from almost any knee condition.
There are many methods of traditional treatment of knee pain conditions. As we know, most conditions are related to degenerative conditions. Degenerative joint conditions are an area where modern medicine can offer only limited help. However, traditional Chinese medicine and acupuncture can be a very effective form of relief.
Medication
There are a number of steps you and your physician may take to determine the cause of your knee pain. At first, it might be sensible to rest your knee for a quick amount of time, however prolonged inactivity ought to be avoided. Your physician can allow you to know which types of exercise are applicable for you. Based on your symptoms and/or diagnosis, your physician might advocate limiting high-impact activities (such as cardiovascular exercise or basketball) and sports that require swift pivoting and sharp turns. Sports like swimming or water aerobics place minimal stress on your knees and are best tolerated when continuing other treatment steps. Exercise could also be prescribed by your physician or a physical therapist in order to increase the strength of the muscles that support the knee. Improving your hip, core, and knee muscle strength is very important in lowering the force transmitted to your knee joint. Too little strength can result in the instability of the joint and increased force, which results in injury or trauma of a joint affected by osteoarthritis. A recently published medical trial showed that a few sessions of guided physical therapy administered by a physical therapist and exercise improved symptoms and performance-based measures much more significantly than medication and therapy regimens involving glucosamine for patients with knee arthritis. This trial showed that exercise should be considered first-line treatment for those with knee arthritis.
Physical Therapy
This article gives an insight into the vast amount of physiotherapy treatment and exercises that can be done with a knee injury or knee surgery, ranging from exercises to more complicated training configurations. These examples show that various research is being put into the treatment of knee injuries and that physiotherapy is well tuned and specific to each particular injury. These treatments are similar around the world, showing that physiotherapy for knee injuries is an evolving science.
When muscular functions around the knee are not working properly, it is important to work on exercises which strengthen the quadriceps and hamstrings, because they are the main shock absorbers for the knee. A person with an injury in one part of the leg may need to do exercises that encourage muscle development in another part of the leg. If the area around the knee is too painful or swollen, exercises to improve the range of motion and strength should be delayed until the swelling has disappeared. These may be followed by exercises to strengthen the thigh and hamstring muscles. For some ‘unloading’ of the knee helpful, this can be done by using a knee brace or taping and with the assistance of a stick or crutches. If only one side of the knee is affected, unloading is achieved by encouraging the patient to lean away from the side of the affected knee.
Advanced Knee Pain Treatment Techniques
Total knee replacement, which traditionally is very invasive in nature, is also becoming less invasive. Rather than the traditional method of accessing the knee by cutting through a large portion of the quadriceps muscle, some surgeons can push this muscle aside and gain an approach from the side of the knee. An even more recent development utilizes a smaller incision, powered instruments, and a special surgical table to assist the surgeon to navigate inside the knee, although the effectiveness of this method is not yet clearly established.
Uni-compartmental (or partial) knee replacement is also a satisfactory option for patients who have isolated damage in one part of their knee. This procedure involves replacing only the damaged area, leaving all healthy tissues untouched. A new or relatively uncommon option for partial knee replacement is the resurfacing of the knee. This usually involves capping the end of the knee joint with a smooth artificial implant. These procedures are far less invasive than total knee replacement and preserve bone and ligaments, making them likely candidates for younger patients with knee pain. A step further, cartilage transplantation or regeneration methods using stem cells provide even more minimally invasive alternatives to knee replacement. Although it should be noted that many of these newer procedures are still considered experimental in nature.
Minimally invasive knee procedures are becoming an increasingly common option for patients with knee pain. The most widely known is arthroscopy – a procedure using small incisions and a camera to diagnose and treat a variety of knee problems. Recently, some arthroscopic procedures are being replaced with even less invasive options. An example would be the use of a needle to get to the joint and inject a substance to stimulate the regeneration of cartilage. Patients who undergo such procedures experience less pain, shorter recovery time, and most importantly, preserve the knee parts until a total knee replacement becomes the only viable option.
Minimally Invasive Procedures
Unicompartmental knee osteoarthritis can be treated with osteotomy, essentially a realignment of the bones around the knee to transfer the weight from the damaged compartment to an undamaged area. High tibial osteotomy has traditionally been an open procedure, but new minimally invasive techniques are showing promise in reducing recovery time and morbidity.
Other procedures that can be performed arthroscopically include synovectomy for inflammatory arthropathies, reduction of acute haemarthrosis, loose body removal, and even microfracture and transplantation procedures for chondral defects.
Anterior Cruciate Ligament ruptures are currently treated with ACL reconstruction. This too has traditionally been done via an open procedure, but in recent times, arthroscopic and more recently all-inside techniques are becoming more popular. Though results from current procedures are good, primary ACL repair (not reconstruction) may be preferable in the future, and again, this can be performed arthroscopically.
One of the most common conditions in orthopedics is a meniscal tear, and it has long been held that these are best treated by partial meniscectomy (removal of the torn piece). However, this has been shown to significantly increase the risk of knee osteoarthritis, and the function of the meniscus as a load bearer and shock absorber has led to an increase in meniscal repair procedures. All-inside meniscal repair devices have significantly reduced surgical time and morbidity compared with older inside-out techniques and are comparable in terms of clinical and anatomic outcomes.
Minimally invasive procedures in orthopedics are the true testaments of how ‘less is more’. By utilizing natural body orifices or small incisions, surgeons can treat intra-articular pathology with little or no damage to the surrounding soft tissues. As this is the exact nature of almost all degenerative disease in the knee, it is a natural home for such procedures.
Regenerative Medicine
When degenerative arthritis or an injury is the cause of significant cartilage damage, doctors will usually advise a total knee replacement. Conventional surgical treatments for cartilage repair or to resurface the knee are not permanent and may ultimately result in a knee replacement. The goal of regenerative medicine is to regrow cartilage in a biological way so the repair is permanent. A second generation ACI procedure is now being used. In this procedure, cartilage cells are harvested from the patient and then sent to a lab, cultured, and multiplied. The cells are then implanted into the patient in a second procedure. In the MACI process, the cells are impregnated onto a membrane and can be implanted into the patient in one-step arthroscopic procedure. A less invasive alternative to MACI cell implantation is the implantation of a scaffold with cultured cells. The latest generation of this is a dissolvable sponge, made from the same material as dissolvable stitches. The sponge will be impregnated with cells and then glued into the defect. These procedures are still considered relatively experimental and are not yet considered standard practice and are only appropriate for certain types of cartilage injuries.
Robotics-Assisted Surgery
This system comprises an image-based preoperative planning module to decide the optimal positioning of the TKR components, and an image-free navigation module to assess the dynamic and clinical mechanical axis of the leg, thus realizing the preoperative planning. The action of the robotic system is held within predetermined areas of bone resection, with the robot providing haptic feedback and preventing the surgeon from moving outside these areas. This serves to ensure the safety of the ligament and surrounding knee structures, and combined with the highly accurate bone cutting, provides the potential for more natural knee kinematics. Published studies with short to mid-term outcomes have been promising, with improved component alignment and no intraoperative complications. However, with potentially prohibitive costs of the robotic systems, further research is required to assess the cost-effectiveness of this technology.
While varying in complexity, innovation on medical devices designed to assist the surgeon to more accurately position the TKR components, improved alignment while simplifying the procedure, has been the focus of significant recent attention. This has included modified extramedullary systems and intramedullary systems to improve the accuracy of bone cuts using mechanical guides, as well as computer navigation systems to provide real-time information on the position of the knee and the alignment of the TKR components. An emerging and promising technology in this field is the development of robotics-assisted surgical systems.
Choosing the Right Knee Pain Specialist in Singapore
Knee pain is a common symptom and complaint. Most people will suffer from some form of knee pain during their life. Knee pain can be mild or severe, and may be the result of an injury or some other medical condition. Knee pain severe enough to limit daily function and reduce an individual’s activity level is estimated to occur in 15% of older adults. The American Academy of Orthopaedic Surgeons believes that there are more than 100 different forms of arthritis, a common cause of knee pain. These conditions affect people of all races and ages. Osteoarthritis is the most common type and usually occurs in people 50 years of age and older, often after a person has had an injury to the knee. With osteoarthritis, the cartilage in the knee joint begins to break down and causes the knee to become painful and stiff. Another common form of arthritis is rheumatoid arthritis, a systemic disease that can attack and destroy knee joints. Other forms of arthritis that can cause knee pain include gout, lupus, and psoriatic arthritis. Although each of these has unique symptoms and signs, often times the result is the same: joint pain and/or knee swelling.
Credentials and Experience
Another example is young athletes with a sports-related knee injury. They may benefit greatly from seeing a sports orthopedic surgeon who is experienced in arthroscopic (keyhole) procedures for conditions such as ligament and meniscus tears. The techniques involved in arthroscopy are more advanced, and an experienced sports surgeon is able to provide a more accurate diagnosis and treatment plan for a patient. This increases the chance of full recovery and return to the previous level of sports activity.
Sometimes, the need to see a particular specialist depends on the type of knee problem a patient has. For those who are seeking to relieve pain from knee arthritis, the best choice may be an orthopedic surgeon who is experienced in joint-preserving surgery for arthritis patients such as high tibial osteotomies or joint surface sparing procedures. This may delay the need for total knee replacement or be a prevention for knee arthritis in younger patients.
Another key factor to consider is the credentials and experience of the knee pain specialist. Patients should ask if the orthopedic surgeon has a fellowship in knee-related injuries (MMed), and if he is trained to manage knee problems conservatively before recommending surgery. In knee pain Singapore, there are many different specialists including general orthopedic surgeons, sports orthopedic surgeons, and a small number who specialize purely in knee surgery. General orthopedic surgeons manage injuries to the musculoskeletal system as a whole, whereas dedicated knee surgeons are more specialized in the management of knee injuries and have more surgical experience in dealing with specific knee-related problems.
Treatment Options Offered
Rest is required in order to prevent further injury. Ice application will help reduce inflammation and pain at the site of injury. This will be most effective in the first 1-3 days following an acute injury. Compression of the injured site will help reduce swelling, and elevation of the injured limb above the level of the heart will also help reduce swelling.
Recent physiotherapy techniques, such as ultrasound therapy, have been found to be effective in treating patellar tendinopathy. In cases of acute traumatic knee pain, where immediate severe pain is felt from an injury, applying the PRICE principle is advised. Protection of the injured site is needed. This can be in the form of crutches following an injury such as an ankle sprain, or the use of a brace in more severe injuries.
There is a wide array of treatment options offered by knee pain specialists in Singapore. The most common treatments prescribed by doctors include physiotherapy, pain and anti-inflammatory medication, injections, and surgery. Treatment options vary depending on the severity of the knee pain experienced by patients. Physiotherapy is commonly used to manage and treat various types of knee pain. The goal of physiotherapy is to help decrease pain and inflammation while improving the strength, flexibility, and control of the knee.
Patient Reviews and Testimonials
If you feel that you have tried your best with a particular treatment, however, it is doing little to relieve you of your pain, you may want to stop and analyze the effectiveness of the treatment. This is the time when you should refer back to your knee pain specialist; however, it would be better to find other patients who have undergone the same treatment. If it is an uncommon treatment, the likelihood of finding someone will be slim. In this scenario, you consult the doctor and ask for an honest opinion about the success of the treatment. If the treatment is generally a hit and miss and your doctor avoids the question with a vague answer, it may be best to stop and consider other options. High-quality and high success rate treatments will have solid reviews from past patients.
Patients who have undergone knee pain treatment with the specialist chosen can provide a very good insight into the effectiveness of the doctor and his treatment. There are no two ways about the usefulness of such information. However, getting to such patients can be difficult. High successful doctors are usually busy and may not be able to spare time for such conversations. It is also unlikely that they would keep track of their past patients. It is best to consult the doctor directly about this. You can also ask the patients in the clinic waiting room. Generic testimonials about a doctor on the internet or his website are a good starting point; however, it is best to go by word of mouth. In this day and age, the internet is full of resources that can help you rate a doctor even without going to him. Sites such as provide information that is very accurate and, more importantly, the site allows interaction between users and the doctors. Many patients can provide their own testimonials for a treatment; this will give you a chance to ask the patient about their treatment (e.g. How was the experience? What treatment was given? etc.).
