Knee Pain A to Z; The Patients Guide to Success | Atlas Health Medical Group

Overview of Knee Pain

Dealing with knee pain can range from annoying to crippling with various stages in between.  For some folks, it’s a minor discomfort that they suck up and power through.  For others, it can be completely debilitating and change their outlook on life.  The Centers for Disease Control (CDC) and Prevention estimates that 1 in 4 Americans experience severe joint pain related to arthritis, which is approximately 15 million people. 1 Globally, 16% of people have knee osteoarthritis and nearly 23% of individuals over the age of 40 have knee osteoarthritis.  This accounts for over 654 million people over the age of 40 worldwide.2  Obesity is a very strong risk factor for knee pain, especially knee osteoarthritis.  The combination of obesity and older individuals increase the odds of symptoms related to osteoarthritis.3  This is clearly a massive issue with growing prevalence year after year making it the leading cause of disability.4  People with osteoarthritis not only have to deal with pain but also an extra financial burden that is estimated to cost them $1,750-$2,800 in additional expenses yearly.5  These factors leave people feeling trapped in chronic pain while also frustrated about the extra expenses and decreased quality of life. 

Risk Factors 6–7 

• Obesity: being overweight or obese puts extra force on the joint beyond its structural abilities that speeds up the deterioration and degeneration of the joint.  
• Muscle Weakness: the muscles around the joint provide strength, protection, stability and increased function.  When they are not cared for, more stress and force is absorbed onto the other structures of the knee weakening the overall joint.
• Previous Injuries or Trauma: past injuries and trauma to the joint enhance long term risk of pain and arthritis.
• Occupation: certain jobs that involve working on your knees bent over, climbing stairs, excess walking, or lifting heavy objects accelerate the wear and tear of the joint. 
• Age: advanced age significantly increases the chance of developing knee pain, particularly osteoarthritis.  

Anatomy of the Knee 8

• Bones: end (distal) of the femur, top (superior) of tibia, and patella (kneecap)

-Function: structure and support

• Tendons: quadriceps tendon, patellar tendon, popliteal tendon

            -Function: connect muscle to bone thus providing strength, dynamic stability and power to the joint

• Ligaments: anterior cruciate (ACL), posterior cruciate (PCL), medial collateral (MCL), and lateral collateral (LCL)

            -Function: connect bone to bone and provide stability 

• Cartilage: strong, hardy and flexible connective tissue that covers the ends of the bones of the joint 

            -Function: allows bones of the joint to smoothly interact and move while also acting as a shock absorber.  

• Meniscus: thick fibrocartilage located between the femur and tibia bones

            -Function: shock absorbers, static stabilizers, and friction reducers during movement

• Bursae: small, fluid filled sacs

             -Function: reduce friction between the bones and soft tissues

• Synovial Membrane and Synovial Fluid: thin connective tissue full of fluid that surrounds the joint and is part of the articular capsule of the joint

            -Function: stabilizes the joint, provides lubrication and reduces friction during movement

Symptoms of Knee Pain

• Joint instability 
• Muscle weakness or wasting
• Throbbing sensation
• Stiffness
• Swelling
• Dull and Achy sensation 
• Intermittent sharp pain with certain movements
• Exercise intolerance 

Diagnosing Knee Pain 9   

Case History:  Getting a good history about the problem from the patient is critically important and sets the table for everything else that follows.  Clinicians that rush through this risk misdiagnosis, inappropriate or ineffective treatment, unnecessary medical expenses, and decreased patient confidence. 

The doctor evaluating your knee pain should begin by asking various questions.  The intent of the questions is to narrow down potential diagnosis and eliminate less likely causes of the pain.  By the time the doctor is done asking you questions they should have a very clear picture of what is going on and then can use in office physical examinations to further confirm what they already suspect.  Questions they may ask you could include: 

• Onset: When did the pain begin?  Did this happen suddenly or slowly build up over some time?  
• Aggravating Factors: What activities, movements or situations make your pain worse? (Example; prolonged standing, going up and down stairs, running etc.)
• Alleviating Factors: What makes the pain better? (Example; rest, ice, over the counter medications, heat etc.)
• Location: Where specifically are you feeling the pain?  Is the pain more on the inside or outside of the knee?  Do you feel pain on the front, back, both or neither? (Typically, this is simplified by just pointing to the exact spots you feel the pain) 
• Pain Quality: How would you describe what the pain feels like? (Example; dull and achy, stiffness, throbbing, popping, locking, swelling, sharp, stabbing, shooting, pins and needles, numbness, weakness, unstable, grinding etc.)
• Severity of Pain: How bad is the pain from 0-10 with 0 being no pain and 10 being extreme pain?  How much pain are you in currently?  How much pain are you in on an average day?  How bad is the pain from 0-10 at its very worst.  
• Timing of Pain: Is the pain always there or does it come and go depending on activities? 
• Previous Injuries or Surgeries: Have you had this type of pain before?  Do you have a history or any trauma to the knee, injuries, accidents or prior surgeries? 
• Treatment History: What treatments have you tried so far for the pain and did they provide pain relief?  How much pain relief did you get?  Have you had any imaging such as x-ray or MRI done previously? 9   

Orthopedic Tests for Knee Pain 10–11

Lachman’s Test

• Assesses: anterior cruciate ligament (ACL)

Patient lies face up on their back with knee slightly flexed to 30 degrees and very slightly rotated outwards.  The doctor will put one hand on the front of the thigh and the other hand just below the knee joint with fingers being the knee.  The doctor will then apply pull the knee forward and feel for a soft or hard endpoint.  Soft endpoints are abnormal and indicate ACL tears.   

Anterior drawer

• Assesses: anterior cruciate ligament (ACL)

Patient lies face up on their back with knee flexed to 90 degrees.  The doctor will sit on the patient’s foot to anchor it in place and then grab the knee from the back with both hands just under the joint and pull forward towards them.  Excessive movement or lack of hard endpoint are abnormal and indicate ACL problems.  

Pivot-Shift

• Assesses: anterior cruciate ligament (ACL), joint stability 

Patient lies face up on their back with leg straight and knee in full extension.  The doctor will grab behind the heel on the foot with one hand and the other hand will grab the leg just below the knee joint.  The doctor will then apply force from outside to in while also slightly rotating the lower leg as they move the leg from extension into flexion.  This tests the stability of the joint, with the main focus on the ACL.  A positive test is when the lower leg shifts away from the upper leg.  This can sometimes be painful.    

Slocum’s Test

• Assesses: anterior cruciate ligament (ACL), joint stability 

Patient lies on their side with the involved knee upwards and leg straight.  The doctor will grab the patient’s leg near the ankle with one hand and rotate the lower leg inwards.  The doctor’s other hand will be placed on the lateral side of the knee and they will apply a downward force to the joint as they move the knee from extension to flexion.  The lower leg or lateral knee moving too much are abnormal indicating instability and potential ACL problems.    

Sag sign

• Assesses: posterior cruciate ligament (PCL)

Patient lies face up on their back with knee flexed to 90 degrees.  The doctor observes how the lower leg appears relative to the knee joint and upper leg looking for sagging.  The patient then contracts their quadriceps muscle and the doctor looks to see if the sag disappears.  Abnormal sag indicates PCL problems. 

Posterior Drawer

• Assesses: posterior cruciate ligament (PCL)

Patient lies face up with the involved knee flexed to 90 degrees.  The doctor will sit on the patient’s foot to anchor it in place and then grab the knee from the back with both hands just under the joint and push backwards towards the patient.  Excessive movement or lack of hard endpoint are abnormal and indicate PCL problems.   

Valgus stress test

• Assesses: medial collateral ligament (MCL)

Patient lies face up on their back with the knee involved in 30 degree flexion.  The doctor grabs the inside of the ankle with one hand and places the other hand over the lateral knee joint line.  The doctor then applies force to the lateral knee and observes how much the joint space opens and much movement there is.  This technique applies pressure to the MCL.  Soft endpoints are the most abnormal and severe and can suggest a tear of the MCL.  

Varus stress tests

• Assesses: lateral collateral ligament (LCL)

Patient lies face up on their back with the knee involved in 30 degree flexion.  The doctor grabs the outside of the ankle with one hand and places the other hand over the medial knee joint line.  The doctor then applies force to the medial knee and observes how much the joint space opens and much movement there is.  This technique applies pressure to the LCL.  Soft endpoints are the most abnormal and severe and can suggest a tear of the LCL.  

McMurrays

• Assesses: meniscus (lateral and medial)

Patient lies face up on their back with the involved knee fully flexed.  The doctor will put one hand on the knee with a finger on the medial joint line and the other hand grabbing the base and heel of the foot.  The doctor will then slowly internally rotate the patient’s tibia (lower leg) while simultaneously applying varus (medial to lateral) stress on the joint.  Then you repeat doing the exact opposite.  The doctor will put one hand on the knee with a finger on the lateral joint line and the other hand grabbing the base and heel of the foot.  The doctor will then slowly externally rotate the patient’s tibia (lower leg) while simultaneously applying valgus (lateral to medial) stress on the joint.  Positive findings are pain, popping, clicking or catching of the medial or lateral joint indicating meniscus problems.     

Bounce home

• Assesses: meniscus

Patient lies face up on their back with the knee in full flexion.  The doctor will grab behind the patient’s involved side ankle and slowly let the knee naturally go into full extension of the joint.  Abnormal findings are when the patient’s knee does not make it into full extension, indicating meniscus problems.  

Joint line tenderness 

• Assesses: meniscus (lateral and medial)

Patient sits down with knees in 90-degree flexion.  The doctor will simply palpate along the medial and lateral joint lines between the bony protuberances.  Induced pain on the medial line is a positive for medial meniscus problems and pain along the lateral line is lateral meniscus problems. 

Apley’s Test

• Assesses: meniscus (lateral and medial)

Patient lies face down on stomach with knees flexed at 90 degrees pointing up to the ceiling.  The doctor will stabilize the patient’s posterior thigh so it doesn’t move and then use both hands to grasp the ankle and bottom of the foot.  They will then rotate the lower leg in each direction and observe.  Finally, they will apply downward pressure on the involved leg and again rotate the lower leg in each direction.  Pain with downward force and rotation is a sign of a meniscus problem or tear on the side of discomfort. 

Ege’s Test

• Assesses: meniscus (lateral and medial)

Patient starts standing up with feet approximately 1 foot apart.  For medial assessment the patient flares their foot out as far as they can (external rotation) and then slowly does a ¾ to full squat down and slowly stands back up.  Abnormal is pain, clicking or popping on the inside of the knee.    For lateral assessment the patient flares their foot in as far as they can (internal rotation) and then slowly does a ¾ to full squat down and slowly stands back up.  Abnormal is pain, clicking or popping on the outside of the knee.  

Patellar Apprehension

• Assesses: Patella Instability 

Patient lies face up on their back with their leg straight in full extension.  The doctor then places their thumb on the lateral aspect of the patella (knee cap) and applies force from lateral to medial while asking the patient to move their leg into 90-degree flexion.  The doctor must maintain the pressure on the patella throughout the movement.  This is then repeated with force on the other side of the patella as the patient goes from full extension into 90-degree flexion once more.  Positive signs are pain or quadriceps muscle recruitment with pain relief on switching sides indicating instability.  

Grind Test (Clarke’s sign)

• Assesses: patellofemoral joint disorder  

Patient lies face up on their back with their legs fully extended.  The doctor will grasp the involved leg with the palm of hand down just above the patella (knee cap) and apply downward and grabbing pressure.  The patient is then instructed to slowly contract their quadriceps muscle.  Pain is a positive sign.

Noble’s compression

Assesses:  iliotibial band syndrome

Patient lies face up on their back with the involved leg fully straight and extended.  The doctor will grasp the heel of the involved leg with one hand and the other hand will apply pressure to the lateral femur just above the knee joint.  The doctor will then move the knee joint back and forth 3-4 times between full extension and 90-degree joint flexion while maintaining the pressure on the femur.  Positive signs are localized pain and/or popping and cracking sounds.  

Imaging for Knee Pain 12

X-Ray (Radiographs)

• Typically, the first imaging ordered
• Detects changes in the bones of the joint (fractures, arthritis, dislocations, bone lesions)
• Does not provide direct information on soft connective tissue
• Does provide small clues to potential soft tissue changes 
• Broadly covered by health insurance
• Cost-Effective

MRI (Magnetic Resonance Imaging)

• Detects changes in bone, cartilage, tendons, ligaments, meniscus, soft tissues
• The gold standard of imaging for the knee joint
• Typically covered by health insurance
• Some companies require x-ray first or physical therapy first before coverage is granted
• Can be done with or without contrast solution 

CT (Computed Tomography)

• Detects changes in the bones of the joint (fractures, arthritis, dislocations, bone lesions)
• Good for detecting specific site of fractures as well as bone healing progress
• Alternative to MRI for patients with implanted hardware
• Images various planes and angles of the joint 
• Typically covered by health insurance
• Some companies require x-ray first or physical therapy first before coverage is granted

Ultrasound

• Detects superficial soft tissue structures (tendons, ligaments, muscle, bursae, cyst)
• Partially evaluates meniscus and cartilage 
• Real time imaging
• Provides needle guidance on treatment for accuracy 
• May be covered by insurance 

Labs to Consider when Evaluating Knee Pain 9

• Complete Blood Count (CBC)
• Comprehensive Metabolic Panel (CMP)
• Vitamin D
• C-Reactive Protein (CRP)
• Erythrocyte Sedimentation Rate (ESR) 
• Testosterone (men)
• Hemoglobin A1c (HbA1C)
• Antinuclear Antibody Test (ANA)

Regenerative Medicine Options for Knee Pain 

 

 

• Prolotherapy: This is the original regenerative injection therapy and consists of an irritant solution injected into tendons, ligaments or joints for chronic musculoskeletal pain.  The irritant is typically dextrose mixed into solution with local anesthetic and saline.13  
• Platelet Rich Plasma or PRP: This regenerative injection is autologous and is taken directly from the patient’s blood.  The blood is processed through a centrifuge which extracts the platelets out of the whole blood.  The platelets are further concentrated down into 4-10 times the strength of circulating baseline levels.  The platelet cell stores many different growth factors that can stimulate a connective tissue healing cascade, aid in local stem cell migration, increase local blood flow and modulate inflammation.  This collective effect provides pain relief and assists in connective tissue repair. 
• Amniotic Fluid Allografts: Amniotic fluid suspensions are full of growth factors, proteins, cytokines, collagen, hyaluronic acid, and signaling factors that can support local stem cell migration, collagen production, and fibroblast migration that cumulatively reduces inflammation and potentially lowers joint pain.  The fluid is obtained by consenting mothers who donate the fluid after an elective cesarean section, thus eliminating any potential ethical concerns.  The amniotic fluids and membranes are processed, filtered, and stored under strict laboratory conditions and must follow federal regulations on minimal manipulation and homologous usage with routine inspection.  These are not live stem cell products due to the stem cells dying in the processing and the need for a drug classification approval of selling a live tissue product.  Amniotic allografts are not stem cells but they do possess regenerative therapeutic potential.  Over the past 10 years research has poured into this area and there is a growing body of evidence that amniotic allografts are beneficial in orthopedic pain conditions such as knee osteoarthritis.14
  • • Not available in the United States unless product follows federal guidelines on minimal manipulation and homologous use
    • Amniotic derived injectable products that are manipulated in laboratory conditions for knee pain or any other condition are only available through investigational new drug applications and approved clinical trials in the U.S.  These products must go through federal approval just like any other medication. 

• ECM Allograft: Extracellular matrix allografts are from dehydrated human amnion/chorion membranes and contain various growth factors, and cytokines that can support local stem cell migration, collagen production, fibroblast migration that cumulatively reduces inflammation and potentially lowers joint pain.
  • • Not available in the United States unless product follows federal guidelines on minimal manipulation and homologous use.
    • Products that are micronized have more than minimal manipulation and are not commercially available in the U.S. 
    • Micronized ECM injectables for knee pain are only available through investigational new drug applications and approved clinical trials in the U.S.  

• Stem Cell Therapy: This is the latest and most advanced form of regenerative orthopedic medicine.  Live stem cells are extracted from the patient’s body via bone marrow aspiration or lipoaspirate from fat tissue.  These are the two most accessed places of abundant mesenchymal stem cells in the human body.  The extraction then can be processed and isolated into stem cells ready for orthopedic knee injections.  Processing must follow federal guidelines on minimal manipulation and homologous use.  Oftentimes physicians will also mix the stem cells with platelet rich plasma for the injection treatment as the PRP tends to act in conjunction with the stem cells for better outcomes.  The PRP/stem cell solution also provides more fluid volume for treatment areas and is typically easier for the doctor to inject.

Knee Pain Conditions:

Osteoarthritis 

Overview: Osteoarthritis or OA is the leading cause of knee pain and most common form of arthritis.  Generally, patients will have OA in both knees but one side may be more painful than the other.  Osteoarthritis was previously described as a “wear and tear” condition associated with aging adults but new research has paved the way for much greater understanding.  It is true that there is a mechanical “wear and tear” component to this degenerative joint condition through excessive use and/or chronic overloading of the joint.  There are also other components that contribute to OA such as excess weight, occupation, blood flow, inflammation, prior injury, lifestyle, nutritional status, muscle strength, smoking, bone density, and physical activity levels.  Knee osteoarthritis generally impacts older adults with increasing prevalence as we age.  15, 16, 17

Signs and Symptoms:

• Joint pain that gets worse with activity 
• Joint tenderness
• Limited motion of the knee
• Swelling
• Joint Deformity 
• Knee Instability
• Dull, achy and stiff sensation 

Diagnostic Evaluation: Knee OA can be diagnosed through a detailed case history and orthopedic physical examinations in office.  If the cause of the pain is still unknown, the doctor can order imaging such as x-ray, MRI, or ultrasound to aid in the diagnosis.  

Standard Treatments: exercise, weight loss, topical pain creams, oral NSAIDs (Ibuprofen etc.), oral analgesics (acetaminophen), duloxetine, knee brace, walking cane, corticosteroid injections, hyaluronic acid injections, and finally knee surgery. 

Regenerative Medicine Treatments

-Prolotherapy:  

• Many studies have demonstrated that prolotherapy is safe and effectively lowers OA knee pain and increases knee functionality.18,19, 20, 21, 22

-Platelet Rich Plasma or PRP:  

• PRP reduces knee OA pain 23, 24, 25
• PRP is more effective than corticosteroid injections (e.g. Cortisone) at 3, 6, and 12 months 26, 27, 28
• PRP is more effective than hyaluronic acid injections (e.g. Synvisc, Supartz, Orthovisc) at 3, 6, and 12 months 29, 30, 31, 32, 33, 34
• PRP increases functionality of the joint more than corticosteroid injections and hyaluronic acid injections 35, 27, 32
• PRP increases the longevity of the knee joint while corticosteroids erode the knee joint and increase patients’ odds of needing total knee replacement surgery 

-ECM Allograft:

• ECM reduces knee OA pain 36
• Protects cartilage 37, 38, 39
• Improves local knee joint environment 38, 39
• Stimulates stem cell activity 39

-Amniotic Allograft:

• Amniotic Allografts outperform Hyaluronic Acid (HA) injections for knee OA pain 40, 41
• Amniotic Allografts reduce knee OA pain and increase joint functionality 42
• Amniotic Allografts modulate joint inflammation 43

-Stem Cell Therapy:  

• Stem Cell therapy reduces knee osteoarthritis pain 44, 45

 

Sprain

Overview: Knee sprains are quite common and most people will experience them at some point in their life.  Sprains involve an injury or damage to one of the ligaments of the knee.  Ligaments connect bones to other bones in the body and provide connective tissue strength and stability of the joint.  They can commonly be overstretched through sports injuries or trauma producing specific knee pain.  

Signs and Symptoms:

• Acute swelling
• Pain
• Inflammation
• Weakness
• Instability
• Tenderness

Diagnostic Evaluation:  Knee sprains can be diagnosed through case history and orthopedic physical examination.  X-rays can be used for acute pain to rule out fractures.  Severe pain may require an MRI for a more detailed assessment.    

Standard Treatments:  Conservative treatments such as rest, ice, and NSAIDs (e.g. Ibuprofen) are the first line approach to care.  Physical therapy may also be considered depending on severity.  More severe sprains are treated with knee braces, temporary leg casts, or surgery in the most severe cases. 46 

Regenerative Medicine Treatments

– Prolotherapy: 

• Helps heal, repair and reduce pain associated with ligament injuries 20, 47, 48, 49, 50, 51

– Platelet Rich Plasma or PRP: 

• Helps heal, repair and reduce pain associated with ligament injuries. 52, 53, 54, 55, 56

– ECM Allograft: 

• Reduces scar tissue formation, supports healing, modulates local inflammation. 39, 14, 57, 58

– Amniotic Allograft: 

• May help in tissue repair and pain reduction but further research is needed for greater clinical insight and use. 14, 57

– Stem Cell Therapy: 

• Shows great potential in connective tissue healing and repair.  Has more expansive research than allograft treatments.  May help in knee ligament repair and pain reduction but remains outside the scope of standard medical therapies for the time being.  59, 60  

Strains

Overview: Strains involve injury, trauma, and/or damage to the tendon.  Tendons are strong connective tissue that connect muscles to the bone.  They give motion to the joint they are attached to and also provide strength and stability. 

Signs and Symptoms:

• Pain
• Tenderness
• Inflammation
• Swelling
• Reduced range of motion

Diagnostic Evaluation:  Knee strains can be diagnosed through case history and orthopedic physical examination.  X-rays can be used for acute pain to rule out fractures.  Severe pain and/or inflammation may require an MRI for a more detailed assessment.  

Standard Treatments: Rest, ice, compression and elevation are the initial conservative treatments.  Over the counter medications such as NSAIDS and acetaminophen may also be advised for pain relief.  Patients are advised to slowly resume stretching and activities after pain has improved.  Physical therapy may be needed in more severe cases.  Surgery is typically not needed unless there is an actual tear of the tendon and the patient has seen improvements with more conservative care. 61   

Regenerative Medicine Treatments

– Prolotherapy: 

• Helps heal, repair and reduce pain associated with tendon and connective tissue injuries 20, 47, 48, 49, 50

– Platelet Rich Plasma or PRP: 

• Helps heal, repair and reduce pain associated with tendon injuries. 52, 53, 54, 55, 56

– ECM Allograft:  

• Reduces pain and scar tissue formation, supports healing, modulates local inflammation 39, 14, 62, 57, 58

– Amniotic Allograft:  

• May help in tissue repair and pain reduction but further research is needed for greater clinical insight and applications.  14, 57

– Stem Cell Therapy: 

• Shows great potential in connective tissue healing and repair.  Has stronger and more collective research than allograft treatments.  May help in knee tendon repair and pain reduction.  Currently promising but outside the conventional standard of care. 59, 60   

Knee Collateral / Cruciate Ligament Injury / Tear

Overview: The knee joint has multiple ligaments that provide strong connective tissue support and stability while limiting excess motion.  The four most important and well-known ligaments of the knee are: Anterior Cruciate Ligament (ACL), Posterior Cruciate Ligament (PCL), Medial Collateral Ligament (MCL), and the Lateral Collateral Ligament (LCL).  ACLs are most commonly injured in sporting activities and typically are fully torn by the trauma.  PCL and LCL injuries can also be from sporting events or motor vehicle accidents and are less common than ACL injuries.  MCL’s injuries are the most common of the four main ligaments cand can occur in many scenarios.  

Signs and Symptoms:

• Sudden Pain
• Hearing a “pop”
• Swelling
• Inflammation
• Instability
• Weakness

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray for acute onset of pain, and MRI for the most detailed assessment. 

Standard Treatments: Initial conservative treatment involves rest and ice with over-the-counter medications such as NSAIDs (e.g., Ibuprofen) and acetaminophen (Tylenol).  This is followed by physical therapy, stretching, activity modifications, and knee bracing.  If the ligament is completely ruptured, then surgical repair will be needed in most cases followed by rehabilitation. 63

Regenerative Medicine Treatments

– Prolotherapy:

• Helps heal, repair and reduce pain associated with ligament injuries 20, 47, 48, 49, 51, 64, 65, 66, 67
• Not effective for complete tears

– Platelet Rich Plasma or PRP:

• Helps heal, repair and reduce pain associated with tendon injuries. 52, 53, 55, 56
• Aids in healing after surgical repair 
• Not effective for complete tears

– ECM Allograft:

• Reduces scar tissue formation, supports healing, modulates local inflammation. 39, 14, 57, 58
• May assist in surgical recovery and healing. 68, 69
• Not effective for complete tears
• Needs further research 

– Amniotic Allograft:

• May help in tissue repair and pain reduction but further research is needed for greater clinical insight and use. 14, 57
• Not effective for complete tears
• Needs further research 

– Stem Cell Therapy: 

• Has more expansive research than allograft treatments.  May help in knee ligament repair and pain reduction. 59, 60, 70, 71    
• Not effective for complete tears

Chondromalacia

Overview: Anterior knee pain involving degenerative changes of the articular cartilage of the patella bone of the knee.  This typically corresponds with softening and erosion of cartilage accompanied by tendinitis, misalignment and muscle weakness.  

Signs and Symptoms:

• Deep joint pain
• Dull and achy sensation
• Pain worse after sitting for long periods of time 
• Anterior knee joint instability 

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray, CT and MRI for the most detailed assessment.

Standard Treatments: Treatment involves ice, massage, ultrasound, over the counter medications such as NSAIDs (e.g., Ibuprofen) and acetaminophen (Tylenol).  This is followed by physical therapy, stretching, activity modifications, knee taping and knee bracing.  Surgical intervention can be considered for prolonged severe pain that is unresponsive to more conservative approaches. 72, 73

Regenerative Medicine Treatments

– Prolotherapy

• Decreases pain at rest and with activities, and improves knee range of motion. 74, 75

– Platelet Rich Plasma or PRP

• Significantly reduces pain, swelling and improves knee function 76, 77, 78
• Improved quality of life. 79

– ECM Allograft

• Needs further research 
• Theoretically beneficial as a novel therapeutic 

– Amniotic Allograft

• Needs further research
• Theoretically beneficial as a novel therapeutic 

– Stem Cell Therapy 

• Decreased pain at 1, 3, and 12 months after treatment with improved range of motion and improved cartilage on MRI 3 months after the treatment. 80
• Needs further research

Bursitis

Overview: Bursae are thin connective tissue sacs of fluid that provide cushioning and reduce friction in the movement of tendons, ligaments, muscles and bones.  This allows the tissue to move smoothly between structures and surfaces while reducing wear and tear.  Bursitis is when this connective tissue structure becomes inflamed.  This can be due to various factors such as; trauma, infection, inflammatory conditions, pressure, new strenuous activities.

Signs and Symptoms:

• Pain
• Tenderness
• Swelling
• Inflammation 
• Increased pain with activity 

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, screening blood work, x-ray, CT and MRI for the most detailed assessment.

Standard Treatments: Typically, rest, ice, compression and elevation is recommended as an initial course of treatment.  Light exercises can be started after the initial inflammation begins to decrease.  If infection is suspected or confirmed, then antibiotics should be taken.  Severe cases may require a steroid injection to get the inflammation under control.  Surgical intervention is rarely needed.  81

Regenerative Medicine Treatments

– Prolotherapy

• Needs further research, minimal data available 

– Platelet Rich Plasma or PRP

• Decreases inflammatory markers in patients with bursitis and osteoarthritis.82

– ECM Allograft

• Theoretically, it may help in tissue repair and pain reduction.83
• Unsubstantiated or no research found to date.

– Amniotic Allograft

• Needs further research, minimal data available
• Theoretically beneficial as a novel therapeutic 

– Stem Cell Therapy 

• Needs further research, minimal data available
• Theoretically beneficial as a novel therapeutic 

Quadriceps Tendinitis

Overview: The quadriceps muscles unite to form a tendon on the superior aspect of the anterior knee that connects to the patella bone.  This tendon and its muscles provide extension to the knee joint.  Inflammation of this tendon is known as quadriceps tendinitis.  This typically develops in middle to older age individuals through repetitive overuse such as jumping sports. 

Signs and Symptoms:

• Anterior and superior knee pain
• Tenderness
• Pain slowly increases over time
• Knee instability and buckling 

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray, and MRI for the most detailed assessment.

Standard Treatments: Rest and avoidance of activities or sports that cause pain.  Gradual resumption of stretching and strengthening exercises.  NSAIDs may be recommended for pain reduction.  Steroid injections should be avoided.  Surgery is rarely needed and reserved for chronic and severe cases that are unresponsive to other therapies.84

Regenerative Medicine Treatments

– Prolotherapy

• Decreased tendon pain.20, 85
• Strengthens tendons by increasing precursors to collagen.86

– Platelet Rich Plasma or PRP

• PRP has positive effect on various tendinopathies.87, 88
• May be beneficial in quadriceps tendon injuries.89
• Deposits new collagen into treated tendons.90

– ECM Allograft

• Reduces pain and improves function in chronic tendinopathies.91
• Needs further research
• Theoretically beneficial as a novel therapeutic injection 

– Amniotic Allograft

• Alters inflammation, increases tenocyte cell density, increases extracellular matrix and collagen deposition.92  
• Needs further research
• Theoretically beneficial as a novel therapeutic injection or in combination with other regenerative orthobiologics. 

– Stem Cell Therapy 

• Needs further research, minimal data available
• Theoretically beneficial as a novel therapeutic 

Patella Tendinitis

 

Overview: The patellar tendon connects the patella (kneecap) to the top of the tibia bone.  This tendon in conjunction with the quadriceps tendon and muscles aids the knee in extension.  Inflammation of this connective tissue structure is called patella tendinitis.  This is typically observed in the youth and young adults involved in jumping sports through overuse and repetitive training.  

Signs and Symptoms:

• Anterior and superior knee pain
• Tenderness
• Pain slowly increases over time
• Knee instability and buckling 

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray, and MRI for the most detailed assessment.

Standard Treatments: Rest and avoidance of activities or sports that cause pain.  Gradual resumption of stretching and strengthening exercises.  NSAIDs may be recommended for pain reduction.  Steroid injections should be avoided.  Surgery is rarely needed and reserved for chronic and severe cases that are unresponsive to other therapies.84

Regenerative Medicine Treatments

– Prolotherapy

• Decreased pain at rest and with sports activity at 45 week follow up after an average of 4 injections.93
• Normalization of tendon appearance on ultrasound following prolotherapy treatment.20
• Lowers overall pain and increases function.85, 94
• Strengthens tendons by increasing precursors to collagen.86

– Platelet Rich Plasma or PRP

• Good safety profile in tendinopathy treatments.88
• Assists in tendon repair after injury.90
• Reduced pain.87, 95, 96
• Improved recovery time and function.97, 98
• Positive long-term outcomes following multiple treatments.99

– ECM Allograft

• Reduces pain and improves function in chronic tendinopathies.91
• Needs further research
• Theoretically beneficial as a novel therapeutic injection 

– Amniotic Allograft

• Alters inflammation, increases tenocyte cell density, increases extracellular matrix and collagen deposition.92  
• Needs further research
• Theoretically beneficial as a novel therapeutic injection or in combination with other regenerative orthobiologics.

– Stem Cell Therapy 

• Promoted patellar tendon repair in animal studies.100
• Significant improvement in patient reported outcome measures at 24 months follow.101
• Improved pain and function on a 5 year follow up for 7/8 patients. 102
• Improved clinical results and connective tissue integrity in athletes.103
• Needs further research

Meniscus Tear

Overview: The meniscus of the knee is a durable and strong connective tissue that absorbs shock and weight bearing load.  It is nestled between the distal end of the femur and the proximal end of the tibia of the knee joint.  The meniscus also provides lubrication and supports normal knee joint range of motion.  Injuries and tears of the meniscus are quite common and can be due to a variety of events that involve twisting, planting, falling, squatting or trauma.  These tears can occur anytime throughout life but are relatively uncommon in patients under the age of 10.     

Signs and Symptoms:

• Quick swelling after injury within minutes to hours
• Localized knee pain
• Tenderness
• Locking or catching feeling 
• Limited movement

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray, and MRI for the most detailed assessment.

Standard Treatments: Icing the knee, NSIADs (Ibuprofen etc.) and physical therapy are first line treatments.  Surgical repair is quite common for meniscus tears for patients that did not see significant improvement through conservative measures.  There are various surgical approaches depending on the location and severity of the tear.  Results vary depending on location, age, type of tear, surgical technique, and strength/stability of the joint.104 

Regenerative Medicine Treatments

– Prolotherapy

• Decreases knee pain and stiffness on 18 month follow up post injection.  96% of patients were satisfied with prolotherapy for meniscus pathology pain. 105

– Platelet Rich Plasma or PRP

• Decreases pain associated with meniscus lesions.106, 107
• May be of benefit in healing and increased functionality after meniscus surgical repair.53, 108, 109, 110, 111 
• Decreases knee pain in adolescents with meniscus tears that were unresponsive to conservative therapy and physical therapy.112
• Stabilizes meniscal lesions and allows athletes to return to sporting activities.113 
• Increases collagen proliferation and stimulates mesenchymal stem cell migration.114

– Amniotic Allograft

• Needs further research, minimal data available
• Theoretically beneficial as a novel therapeutic 

– Stem Cell Therapy 

• Promotes meniscus healing in animal models.115, 116, 117
• Reduces meniscus knee pain and restores meniscus tissue on post-treatment MRI.118, 119 
• Improves avascular meniscal repair surgical outcomes.116, 120
• Promising results in-vitro and in-vivo research on meniscus repair.121

Patellar Subluxation / Dislocation

Overview: The patella bone (kneecap) sits on the anterior aspect of the knee and is connected to the quadriceps tendon and patellar tendon.  It assists in extension movement of the knee and provides protection to the front of the knee joint from trauma.  A subluxation is when the patella is moved partially outside of its normal anatomical position.  A dislocation is when the patella is traumatically moved completely away from its normal anatomical position.  These events typically occur in younger adults with the knee near full extension and the lower leg turned slightly outwards.    

Signs and Symptoms:

• Anterior knee pain
• Large swelling 
• Tenderness
• Instability

Diagnostic Evaluation: Detailed case history, orthopedic physical examination, x-ray, and CT for the most detailed assessment. 

Standard Treatments: Conservative treatments such as rest, ice, compression and elevation are typically advised.  Surgical intervention is considered if the patient continues to experience chronic pain, bone fragments are observed on imaging, complete or partial ligament tears are present, or if the patella begins to frequently dislocate.122 

Regenerative Medicine Treatments

– Prolotherapy

• Needs further research, no data available
• Theoretically beneficial as a novel therapeutic

– Platelet Rich Plasma or PRP

• Accelerates healing and regeneration following surgery.123, 124
• Speeds tendon healing times and collagen deposition in animal models.56
• Needs further research, minimal case studies available 
• Theoretically beneficial as a novel therapeutic 

– Amniotic Allograft

• Needs further research, no data available 
• Theoretically beneficial as a novel therapeutic

– Stem Cell Therapy 

• Needs further research, minimal case studies available 
• Theoretically beneficial as a novel therapeutic

Cortisone: Friend or Foe?

 

 

 

STEROID INJECTIONS:  The Good, the Bad, and the Ugly 

 Patients struggling with chronic knee pain from arthritis have various injection options available.  The most commonly used is corticosteroids in primary care as well as pain management.  But is this your best option?  Ultimately patients must decide on an injection based on their goals and priorities. 

• If your main concern is insurance coverage, then steroid injections will meet your needs. 
• If your focus is pain relief over 2-6 weeks, then steroids might be right for you. 
• If your main objective is long term pain relief, then steroids should definitely be avoided.
• If you want increased function of your knee joint, then steroids should be avoided. 
• If you really don’t want knee surgery or a total knee replacement, then the last thing you would do is have a steroid injection.

Corticosteroid injections aren’t inherently bad or good.  They have a defined application in medicine and many folks will choose to try them.  Be educated and informed on your healthcare decisions and select the option that best meets your needs independent of insurance mandates, large bureaucracies, and physicians not up to date on the current literature. 

When steroid injections are not a good option for long term knee joint health.  

• Recent meta-analysis of 30 different Randomized Controlled Trials (RTC) comparing knee injection options for osteoarthritis (OA) show steroid injections are less effective than placebo at 12 months.  PRP or platelet rich plasma injections are more effective for knee OA at 3, 6, and 12 month follow ups in terms of pain reduction and increased joint functionality.125
• Another long-term study on the impact of steroid injections shows that each steroid treatment increases your chance for total knee replacement by 9.4%.126

Nutritional Considerations

 

Mediterranean diet:

Overview:  The Mediterranean Diet refers to the dietary customs and cuisines of people living in countries around the Mediterranean basin region.  This particular diet has long gained recognition for longevity and overall health as people continually observed it outperforming the standard American and Northern European dietary customs.  The diet broadly consists of; high vegetable, fruit, legumes, nuts, seeds, fish and seafood consumption.  Moderate consumption of chicken, dairy products, eggs, and olive oil.  Minimal consumption of red meats, processed foods, carbohydrates and fried foods.  This diet also has minimal but frequent consumption of red wine, as the preferred alcoholic beverage.127, 128 

Benefits of the Mediterranean Diet for Chronic Knee Pain 127, 128, 129, 130, 131

• Higher quality of life for Osteoarthritis patients, lower prevalence of knee arthritis overall, less inflammation and cartilage degeneration  
• Increased vitamins, minerals and antioxidants 
• Lowers chance of knee pain and progression of symptoms 
• Improves Extracellular Matrix of the knee    
• Anti-Inflammatory
• Improved range of motion of the knee joint

Omega-3 Fatty Acids:

Overview: Omega-3 polyunsaturated fatty acids, commonly called omega-3’s, are essential fats needed for the human body.  They are not produced by humans naturally and must be obtained through diet/nutritional sources.  Common foods that are high in Omega-3’s would be salmon, sardines, other deep-sea cold-water fish, flaxseed, chia seeds, and walnuts to name a few.  Omega-3’s are also widely found in fish oil supplements that can be purchased in most pharmacies, grocery, health food and online stores.  The Mediterranean Diet generally has higher amounts of Omega-3’s than the standard American Diet.  

Benefits of Omega-3 Fatty Acids on Knee Health 132, 133, 134, 135, 136, 137, 138, 139

• Low Omega-6/Omega-3 ratio decreases pain, increases functionality, and decreases pain sensitivity
• High Omega-3’s are associated with decreased patellofemoral cartilage loss in the knee
• Protects against cartilage loss in animal models
• Reduces knee pain in combination with L-Serine
• Improves wound healing and osteoarthritis severity following injury in animal model
• Decreases risk of developing knee osteoarthritis

Anti-Inflammatory Foods:

Overview: Foods that produce systemic decreases in inflammatory markers throughout the body are otherwise known as anti-inflammatory.  These foods typically are fruits and vegetables that have high polyphenol content.  The standard American Diet typically has insufficient amounts of anti-inflammatory foods and excess amounts of inflammatory foods.  

Anti-Inflammatory Foods for Knee Pain:

• Blueberries: Daily consumption of blueberries reduce knee osteoarthritis pain, stiffness while improving walking gait and ability to complete daily living activities.140
• Strawberries:  Daily consumption of frozen strawberries reduced inflammatory blood markers, constant pain, intermittent pain and total pain in obese adults with osteoarthritis of the knee.141 
• Vegetables
• Legumes
• Fruits
• Fish
• Whole Grains

Foods to Avoid:  Certain foods are known to induce inflammation in the body with specific foods or beverages known to increase the risk of developing knee osteoarthritis.142

• Soft drinks
• Milk
• Saturated fats 
• French Fries
• Processed Meats
• Refined Grains
• Red Meats
• Poultry
• Pizza 
• Margarine
• Sugary drinks
• Eggs
• Snacks
• Desserts
• Salad Dressings  

Stretches for Knee Pain Relief 

 

 

 

Heel Cord Stretch

Main muscles stretched: Gastrocnemius-soleus complex

• Repetitions: 3 sets of 3
• Days per week: 5-7

Step-by-step Instructions

• Stand facing a wall with your pain free leg forward with a slight bend at the knee. Your painful leg is straight and behind you, with the heel flat on the floor and the toes pointed in slightly facing the wall.
• Keep both heels flat on the floor and press your hips forward toward the wall.
• Hold this stretch for 30 seconds and then relax for 30 seconds. Repeat for 3 sets.

Standing Quadriceps Stretch        

Main muscles stretched: Quadriceps.  You should feel this stretch on the front upper leg

• Repetitions: 3
• Days per week: 5

Step-by-step Instructions

• Hold on to the back of a chair for balance
• Bend your knee and bring your heel up toward your back buttock.
• Grab your ankle with your hand and gently pull your heel up closer to your body.
• Hold this position for 30 to 60 seconds.
• Repeat with the opposite leg.

Supine Hamstring Stretch         

Main muscles stretched: Hamstrings.  You should feel this stretch at the back of your upper leg and behind your knee.

• Repetitions: 3
• Days per week: 5

Step-by-step Instructions

• Lie on the floor, stomach upwards, with both legs bent approximately 90 degrees
• Lift one leg off of the floor and bring the knee toward your chest.
• Grab both your hands behind your thigh below your knee.
• Straighten your leg and then pull it gently toward your head, until you feel a stretch. (If you have difficulty grabbing your hands behind your leg, loop a beach towel around your thigh. Grasp the ends of the towel and pull your leg toward you.)
• Hold this position for 30 to 60 seconds.
• Repeat with the opposite leg.

Half Squats         

Main muscles stretched: Quadriceps, gluteus, hamstrings.  You should feel this exercise at the front and back of your upper legs, and your buttocks

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Stand with your feet shoulder width apart. Your hands can rest on the front of your legs or reach straight out in front of you.
• Keep your chest upright and forward and slowly lower your hips about 10-12 inches, as if you are sitting down into a chair.
• Place your weight in your heels and hold the squat for 5 seconds.  
• Power up through your heels and bring your body back up to standing position.

Hamstring Curls          

Main muscles stretched: Hamstrings.  You should feel this exercise at the back of your upper leg.

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Hold onto the back of a chair or a wall for balance.
• Bend your painful knee and raise your heel toward the ceiling as far as possible without pain.
• Hold this position for 5 seconds and then relax. Repeat.

Calf Raises 

Main muscles stretched: Gastrocnemius-soleus complex.  You should feel this exercise in your calf muscle of the lower leg.

• Repetitions: 3 sets of 7
• Days per week: 7

Step-by-step Instructions

• Stand with your weight evenly distributed over both feet. Hold onto the back of a chair or a wall for balance.
• Lift your unaffected foot up and off of the floor so that all of your weight is placed on your affected foot.
• Raise the heel of your affected painful side as high as you can, then lower.
• Repeat 7 times per set.

Leg Extensions          

Main muscles stretched: Quadriceps.  You should feel this exercise at the front of your upper leg.

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Sit up straight on a chair.
• Tighten your thigh muscles and slowly straighten and raise your affected painful side leg as high as you can.
• Squeeze and contract your thigh muscles and hold this position for 5 seconds. Relax and bring your foot to the floor. Repeat.

 Straight-Leg Raises         

Main muscles stretched: Quadriceps.  You should feel this exercise at the front of your upper legs.

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Lie on the floor with you back down and stomach up with your elbows directly under your shoulders to support your upper body.
• Keep your affected leg straight and bend your other leg so that your foot is flat on the ground.
• Tighten the thigh muscle of your affected leg and slowly raise it up 6 to 10 inches off the floor.
• Hold this position for 5 seconds and then relax and bring your leg to the floor. Repeat.

Straight-Leg Raises (facedown)  

Main muscles stretched: Hamstrings, gluteus.  You should feel this exercise at the back of your upper leg and into your buttocks.

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Lie on the floor on your stomach, facedown with your legs straight. Rest your head on your arms.
• Squeeze your gluteus and hamstring muscles of the affected leg and raise the leg upwards to the ceiling as high as you can go.
• Hold this position for 5 seconds. 
• Lower your leg and rest it for 2 seconds. Repeat.

Hip Abduction         

Main muscles stretched: Abductors (outer and upper leg), gluteus.  You should feel this exercise at your outer thigh and buttocks.

• Repetitions: 4 sets of 15
• Days per week: 5

Step-by-step Instructions

• Lie on your side with your injured leg on top and the bottom leg bent to provide support.
• Straighten your top leg and slowly raise it to approximately 45°, keeping your knee straight.
• Hold this position for 5 seconds.
• Slowly lower your leg and relax it for 2 seconds. Repeat.

Hip Adduction         

Main muscles stretched: Adductors (inner and upper leg).  You should feel this exercise at your upper inner legs.

• Repetitions: 3 sets of 15
• Days per week: 5

Step-by-step Instructions

• Lie down on the floor on the side of your injured painful leg with both legs straight.
• Cross the uninjured leg in front of the injured leg.
• Raise the injured leg 6 to 8 inches off the ground.
• Hold this position for 5 seconds.
• Lower your leg back down and rest for 2 seconds. Repeat.

 Leg Presses  

Main muscles stretched: Quadriceps, hamstrings.  You should feel this exercise at the front of your hip, and the front and back of your upper legs.

• Repetitions: 4 sets of 8
• Days per week: 5

Step-by-step Instructions

• Place the center of the elastic band or beach towel at the arch of your foot and hold the ends in each hand. Lie on the floor with your elbows bent, stomach and face-up.
• Tighten the thigh muscle of your affected painful leg and bring your knee toward your chest gradually.
• Flex your foot and slowly straighten your leg directly in front of you, pushing against the elastic band or beach towel.
• Hold this position for 2 seconds. Relax and bring your leg to the ground. Repeat.

Disclaimer: Information presented and provided is of educational purposes only is not intended to be specific medical advice.  Individuals seeking specific medical advice should consult with their physical therapist, PCP, or orthopedic specialist.

Outside the Box treatment Considerations:

Peptides: 

BPC-157:  This peptide is a partial sequence from an amino acid chain known as body protection compound (BPC).  This particular peptide was found in human gastric juice (stomach acid) and became of particular interest for its role in accelerated tissue healing.  BPC-157 is highly experimental and is still in early stages of research and study and has not been FDA approved for any particular condition to date.  This treatment is years away from standardization and patients and physicians need to be very cautious in generalizing data/results from animal studies into human benefits.  This peptide requires a prescription from a physician and is compounded in federally regulated U.S. laboratories.  Patients who buy this peptide online are engaging in highly risky and dangerous activities.  This product should never be taken without a prescription and physician monitoring.  Most online versions of this peptide are compounded in unregulated underground pharmacies in China.  

Potential Benefits:144, 145, 146

• Promotes tendon healing in rats 
• Improves tendon, ligament and bone healing in vitro and in vivo animal models

AOD9604:  This peptide is a synthetic 15 amino acid derivative from growth hormone that does not stimulate IGF-1, which has been associated with detrimental effects from growth hormone injections.  Basically, this peptide was designed to obtain the benefits of growth hormone injections, while minimizing or eliminating the downside effects of intra-articular injections.  AOD9604 is highly experimental and is still in early stages of research and study and has not been FDA approved for any particular condition to date.  This treatment is years away from standardization and patients and physicians need to be very cautious in generalizing data/results from animal studies into human benefits.  This peptide requires a prescription from a physician and is compounded in federally regulated U.S. laboratories.  Patients who buy this peptide online are engaging in highly risky and dangerous activities.  This product should never be taken without a prescription and physician monitoring.  Most online versions of this peptide are compounded in unregulated underground pharmacies in China.    

Potential Benefits:147

• Reduced joint inflammation, reduced pain and cartilage regeneration in rabbit animal study  

LDN:

Low Dose Naltrexone or what’s commonly referred to as LDN, is exactly what it sounds like.  It is a very low dose of the prescription medication Naltrexone.  This medication is mainly used to treat opioid addiction and overdose by antagonizing opioid receptors and displacing the opioids, which in turn lowers their effect.  Oral doses of this medication are typically 50mg per day, but LDN is in the range of 1-5mg per day.  The medication is very interesting by the fact it acts by different mechanisms at different doses.  At very low doses, Naltrexone acts as anti-inflammatory in the central nervous system of the body, increases the body’s own production of endorphins, and modulates the immune system.  LDN is typically taken orally at night before bedtime with its effects carrying over to the next day.  LDN is not FDA approved for any particular condition and is used off-label by some physicians for adjunct care in cancer, autoimmune conditions, mental health, and pain management.  Off-label use is considered investigational and patients should have full consent and knowledge before considering this therapeutic.148, 149  

Potential Benefits:148, 149, 150, 151

• Modulates inflammation providing theoretical use as a novel anti-inflammatory
• Enhances endogenous analgesic effect in the body
• May improve quality of life for chronic disease patients

Curcumin:

Derived from the common spice turmeric, curcumin has steadily gained usage in the supplement form and continues to be studied globally.  Turmeric has been used in herbal medicine for many hundreds of years, especially in southeast Asian countries.  Recent focus has delved into the roots anti-inflammatory benefits, especially for chronic inflammatory conditions.  

Benefits:152, 153, 154, 155, 156, 157

• Protects against cartilage breakdown
• Modulates Inflammation producing Anti-Inflammatory effects 
•  Reduces pain, improves function, and reduces stiffness better than acetaminophen in patients with knee osteoarthritis
• Similar pain reducing effect as Ibuprofen, but curcumin had better patient satisfaction scores, better timed walk and stair climbing scores  
• Better safety profile than Ibuprofen
• Reduces knee pain in osteoarthritis patients
• Similar pain relief as compared to other NSAIDs 

CBD:

Cannabidiol, commonly referred to as CBD, is a constituent of the cannabis plant with a very long history of use in herbal medicine, ancient medicine, and recreational medicine.  CBD does not produce mental effects that THC does from the cannabis plant.  The effects of cannabis have long been grouped together, but modern science and availability has now increasingly separated the two distinct constituents.  CBD has recently become mainstream in America with increased acceptance of medical and recreational marijuana.  Most people know friends or family members that have tried the product at some point in time.  Professional athletes now openly endorse its use, but its applications in evidence-based medicine have not caught up with its universal popularity.  CBD is currently available in supplement form and is not a prescription medication.  

Potential Benefits:158, 159, 160, 161

• Reduces osteoarthritis pain in dog and rodent models 
• Anti-Inflammatory effects
• Analgesic pain-relieving effects noted in animal models
• Cost-effective pain relief compared to conservative care strategies for knee pain when in conjunction with all cannabis plant components
• Anti-arthritic effect in murine animal models
• Decreases pain and increases activity in dogs with osteoarthritis

Knee Pain Common Questions

 

How do I know if my knee pain is serious?

• Pain that is chronic and is 7/10 or higher is severe and warrants medical care.  Sudden trauma or injury that produces severe knee pain, will require immediate medical care and patients should report to the ER for evaluation.  

What can I do to relieve knee pain?

• Conservative at-home strategies for knee pain relief can include; rotating between ice and heat, stretching, light exercise and movement, staying well hydrated with water, avoiding sugar in your diet, and getting a proper night’s rest.  Always consult with your doctor for medical advice and additional considerations.    

What causes knee pain without injury?

• Various things can give people knee pain without specific injuries such as other medical conditions (Gout, RA, diabetes etc.), inflammation, infection, medication side effects, ligament laxity, poor diet, dehydration, obesity, poor blood flow, and nerve irritation to name a few. 

Is walking good for knee pain?

• Walking is one of the very best exercises for knee pain.  Aim for 10,0000 steps per day if physically able. 

What does arthritis in the knee feel like?

• Knee arthritis produces a dull and achy sensation deep in the joint that can also be accompanied with weakness, instability, swelling, tenderness and throbbing pains.  

Are stairs bad for knees?

• Going up or down stairs can put extra pressure on the supporting structures of the knee joint (tendons, ligaments, meniscus, muscles) and make pain worse, especially in older people.

What are the 5 worst foods to eat if you have arthritis?

• High sugar foods (cereal, baked goods, ice cream, candy, soda etc.)
• Fried foods
• Highly processed foods
• Foods that contain gluten
• Foods with High Fructose Corn Syrup 

When is it time for Surgery? 

There are a multitude of factors to consider before deciding on moving forward with surgery.  Before I get into the specific factor’s patients should consider, I would like to say upfront that surgery is not the end of the world and for some patients is clearly the best option for them.  Surgery has continued to improve and advance over time which has led to faster recovery times and less invasive options.  Surgery has specific benefits and limitations and the patient should be aware of the totality of this decision so they can comfortably and confidently pick the best treatment for their knee pain.

Factors that should be considered before moving forward with surgery:

• Pain: On a normal typical day, how bad is your pain on a 0-10 scale with 10 being the most?  Generally, patients that are at 8/10 or higher may need to consider surgery.  
• Health of the Joint:  Has your knee been through many injuries, procedures, trauma, and/or surgeries already?  Is there extensive damage noted on x-ray and MRI that correlates with the pain you feel?  If so, you may need surgery.  
• Lifestyle: Patients that are committed to a healthy lifestyle with a well-balanced anti-inflammatory diet, daily exercise, good sleep, and normal body weight tend to be able to avoid needing surgery.  Patients that are already overweight or obese with poor lifestyles and have no interest in healthy changes are substantially more likely to need surgery.  For these individual’s surgery is a good option.  
• Finances: Many people are living with a fixed income or limited finances and allow that to dictate their medical care instead of advanced science.  If your main objective is insurance coverage, then surgery should be considered. 
• Support System: Some surgeries have long and extensive recovery periods.  Patients will need friends, family, and loved ones around for support with daily living activities, transportation, and mental health.  
• Treatment History: Have you tried every possible treatment option for knee pain relief?  Did you only try insurance mandated treatments?  Some people are able to get substantial long lasting pain relief through outside the box therapies such as regenerative medicine.  Always advocate for yourself in the medical system and push the envelope for the best care available.    
• Age: Generally speaking, the older you are the more likely you will need surgery and the younger you are the more likely you won’t.  This obviously depends on the case and situation at hand.  Additionally, some patients will reach advanced age and will not be able to handle surgery and its associated rehabilitation.  For these people, pain management may be their best option.   
• Recovery Time: Are you able to accommodate your life in order to complete the necessary and proper recovery needed?  For many younger patients, this is definitely an issue as they are trying to balance work, travel, raising children and running the family.  
• Surgeons Success Rate: It’s always good to look into the hospital, clinic, and doctors’ clinical outcomes ahead of surgery.  There are cases where surgery is the best choice but the surgeon is not.  You want to feel comfortable with your surgeon and their staff.  The best surgeon has consistently high success, minimal complications, and good bedside manner.    

Additional Resources

 

 

 

 

 

 

 

Facebook Knee Pain Support Group

Author:

Dylan Krueger, NMD

 

Atlas Health Medical Group

 

References:

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19. Arias-Vázquez PI, Tovilla-Zárate CA, Legorreta-Ramírez BG, et al. Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials. Adv Rheumatol. 2019;59(1):39.

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21. Wee TC, Neo EJR, Tan YL. Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis. Journal of Clinical Orthopaedics & Trauma. 2021;19:108-117.

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