Knee pains are common enough with osteoarthritis of the knee, or after sports injuries or other unusual causes like gout rheumatoid arthritis etc Osteoarthritis of the knee results from age related degenerative changes in the joint and in the muscles responsible for movement of the joint. Osteoarthritis has now become national disease in India with most people in their 4th and 5th decades suffering from it. This entity is more commonly seen with women, the obese and the elderly.
Ironically the pain in these patients is experienced mainly from the muscles that move the joint rather than directly from the joint . This is particularly true in those patients where X-ray show only mild to moderate signs of arthritis. Good orthopaedic surgeons would usually advise this population of patients to manage conservatively till surgery is indicated. The reason for this is that the artificial knee cannot perform all the movements carried out by the natural knee. And the artificial joint has a specific life span. As a result good surgeons tend to operate only when joint replacement is the only way to relieve the knee pain and restore activity to the patient. Therapy for knee joint pain depends on the source and the gravity of the problem.
Often these patients have pain
Below the knee cap – This is a pain from the quadriceps and not from the knee joint per se.
Below the knee on its inner aspect from the spasm of
the inner thigh muscles insertion called the “pes anserine “ tendon This is a common tendon for 3 muscles the medial hamstring, gracilis and the sartorius muscle .
The pain from the joint itself is seen along the joint line which can be felt . when the knee is bent.
In most patients pain is from a combination of all these.
Difficulty in climbing down the stairs and later up the stairs
Difficulty in standing
Difficulty in walking
Difficulty in squatting
Difficulty in performing prayers, sitting cross legged, etc
After a while, many patients complain of pain in the other knee as well along with low backache
The reason for the pain and the common occurrence in population is lack of exercise. Traditional Indian life used to entail considerable exercise to the knee with the cross legged sitting , walking as a part of daily work, use of the Indian toilet etc. With the advent of sitting in chairs, travelling in personal conveyances life has become sedentary with initial disuse that leads to differential shortening of muscles across the knee joint. These shortened muscles in turn bring the bones of the knee nearer to each other to cause friction and cartilage damage. Most patients complain of pain in the earlier stages because simple daily activities stretch shortened muscles towards painful levels. In this the Hamstring muscles at the back of the legs are stronger than the quadriceps. Because the weaker quadriceps has to work against the hamstrings to straighten the leg for standing walking etc. it becomes painful. Most knee pain patients complain of pain in the front of the knee. When the medial hamstring muscles are shortened the patients complain of pain just below the knee on the inner calf area. These are the patients who complain of pain that interferes with their life but when an x-ray is taken it shows only mild to moderate changes in the joint. A common advice from good orthopedic surgeons at this stage is for the patient to wait till the pain interferes with normal life. This is the stage where there are only mild to moderate bone and joint changes but the patients are in considerable pain.
This is also the stage when the organic pain of osteoarthritis keeps sending pain signals to the nerves in the spinal cord. As this continues constant bombardment of the spinal cord by pain signals leads to excitation of the pain pathway called “central sensitization”. This means that the spinal cord is sensitized initially and later oversensitive to the pain. Any pain in the knee is felt to be more because the spinal cord has the ability to actually multiply the pain. This slow but ongoing involvement of the nerves and spinal cord is called a “neuropathic pain”. Once pain acquires a neuropathic nature, patients have considerable distress but try to pull on as per the doctors’ advice but find it difficult to overcome this combination of organic and neuropathic pain. It is this category of patients who benefit tremendously from our treatment that targets the nerves to desensitize the spinal sensitization that has occurred. This is an innovation at Ashirvad clinic based on a study which describes the anatomy of nerves that supply the knee joint.
The approach to knee pains is comprehensive, with
2. USG guided Nerve stimulator confirmed blocks of the nerves around the knee that supply the pain fibres. This block ensures instant pain relief up to 60-70%. This will reduce the pain input through the nerves to reduce or abolish the neuropathic pain.
3. Specific treatment of pain generators , the muscles : IMS of specific muscles involved in moving the knee. As patients go through with this \ treatment they improve in a step by step manner with relief of pain at rest as well as with increasing activity.
4. In specific cases where a major pain generator is diagnosed to be from the joint itself, Intraarticular injections ( injection into the joint) low dose steroid ( just 10 mg as compared to the usual 80 mg ) are performed where necessary. In very selected cases injection of hyaluron, a lubricant may be given
5. Physical therapy: Advice on what aquatic or pool exercises are beneficial to you will be given. For those who do not need these initial stretching exercises and later strengthening exercises for the muscles involved in moving the knee are taught. Here there is considerable interaction between the pain therapist and the physiotherapist to optimize the benefit to the patient. It is only Later that strengthening exercises for Quadriceps adductors etc are taught ,
6. Weight loss, essential for sustained benefit from the treatment is advised by referral to a dietician
7. Posture correction, nutritional correction, lifestyle modification and patient education are other aspects of complete therapy
Once the patient goes through this treatment they come to realize the importance of regular exercise that keeps their knees strong and healthy. From here it is a short way to a normal life full of activity.
Knee injections followed by IMS is an innovation that has yielded tremendous satisfaction to patients as well as to us of a work well done.