By: Zach Vinton OMS-IV
Knee pain is an increasingly common complaint in the United States affecting approximately 25% of adults with an estimated increase in prevalence of 65% over the past two decades.1 Although there are many potential causes of knee pain, the most common chronic causes include osteoarthritis, patellar tendinitis, prepatellar bursitis, and patellofemoral pain syndrome (chondromalacia patellae). This article will discuss the risk factors and treatment of these knee pain etiologies.
One of the most common causes of work disability affecting approximately 32 million adults in the United States is osteoarthritis.2 Osteoarthritis is caused by the normal wear and tear of cartilage present between bones. Common risk factors include increasing age, injury, and overuse of the joint. Management depends on the severity of the disease and is aimed at reducing pain, improving function of the joint, and protecting it from further damage. Initially, recommendations for osteoarthritis with all degrees of severity include nonpharmacologic measures such as exercise, weight loss, and physical therapy (PT). The goals of PT are to strengthen muscles surrounding the knee, improve stability, and increase range of motion. If adequate pain relief isn’t experienced with these methods, topical non-steroidal anti-inflammatory drugs (NSAIDs) or topical capsaicin may be used. A study completed by the University of Oxford found that around 60% of patients using topical NSAIDs gained at least a 50% improvement in pain compared to placebo.3 In patients who don’t receive adequate relief with these methods, options include interventional pain management techniques including genicular nerve blocks or ablation, intraarticular glucocorticoid injections, as well as regenerative medicine, all of which are performed by a trained pain medicine specialist. The genicular nerves send pain signals from the knee and with the help of ultrasound and fluoroscopy (in imaging technique), may be “blocked” or ablated, which can help reduce pain signals. Glucocorticoid injections into the joint may also be used for short-term relief of pain. More modern therapy called “regenerative medicine” may utilize stem cells and platelet-rich plasma (PRP) to promote regeneration and healing of the tissue in the joint.4 If the pain is resistant to all non-surgical options for treatment, treatments such as a total knee replacement may be explored with an orthopedic surgeon.
Patellar tendinitis is also known as “jumper’s knee” and most commonly effects young athletes that play sports requiring jumping and landing like basketball, volleyball, and track and field. However, muscle imbalances, or a sudden change in intensity or frequency of exercise can also contribute to the development of patellar tendinitis. The goal of management is to reduce pain and inflammation. Initial management includes refraining from participation in activities contributing to the condition. Ice and topical or oral NSAIDs can also help relieve acute symptoms. Physical therapy is another important aspect of management and focuses on stretching and progressive tendon-loading exercises which are useful for recovery and prevention of episodes in the future.6 Other treatments with limited evidence supporting their effectiveness includes both knee-wraps and taping. Extracorporeal shock wave therapy may be used, however further studies are needed to determine it’s effectiveness.6 Glucocorticoid and PRP injections or surgery may be considered in patients who fail to improve after conservative approaches.
Prepatellar bursitis is also known as “housemaid’s knee” and is due to inflammation of the small fluid filled sac in front of the patella, which helps reduce friction in your knee joint. Individuals who may be more susceptible for the development of prepatellar bursitis include carpet installers, gardeners, roofers, or athletes who all experience repetitive kneeling. Injury to the knee from trauma, infection, or other conditions like rheumatoid arthritis and gout may all also increase risk. Management, like in tendinitis is aimed at reducing inflammation and pain in addition to treating the underlying cause if it is comorbid (like gout for instance).7 Prepatellar bursitis is usually self-limited, therefore management often involves avoiding repetitive kneeling or the use of protective knee pads or braces if kneeling can’t be avoided. Short-term NSAIDs may also be used for relieving acute pain. If bursitis is refractory, nerve ablation may also be performed with a pain medicine specialist as an alternative to surgery.8 If the bursa becomes infected, joint aspiration and antibiotics may be needed.
Patellofemoral pain syndrome is also known as “runner’s knee” and involves the breakdown of cartilage under the patella (kneecap). This more commonly occurs in younger patients who perform activities with high impact to the knee such as cycling, running, or jumping. However, muscle imbalance or weakness of the quadricep muscles (thighs) may also contribute. Management is based on reducing pain, improving the alignment and tracking of the patella.9 It is recommended to reduce how much high-impact knee activity is performed and with severe symptoms, complete cessation is recommended. Alternatives include swimming, stationary biking, upper body cycling, or other activities which do not aggravate the injury. Icing and NSAIDs may also be temporarily used for acute pain. Physical therapy is an important aspect of recovery and is focused on stretching and exercises of the core, knee flexors and extensors, IT band, and hip abductors.8 Other therapy that can be used includes orthotics, dry-needling taping, and bracing. Injections of glucocorticoids, hyaluronic acid, and PRP may also be considered if pain is refractory to conservative measures.
There are numerous causes of knee pain which can be functionally limiting and frustrating to experience. The Denver Spine and Pain Institute are specialists in management of these conditions and are trained to perform interventional techniques such as joint injections and PRP in order to help reduce pain. Please contact us for a consultation if you are interested in getting back to being pain free.
Give us a call today to schedule an appointment with one of our excellent providers at The Denver Spine and Pain Institute. 303-327-5511.
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