Knee Pain is the most common joint that I evaluate and treat in my office. As we age, our knees will have degenerative changes. Degenerative changes occur with normal wear and tear. For example, most anyone over the age of 35 has small meniscus tears or fraying of the meniscus. This can be seen on MRI and should be an expectant finding, but not a compelling reason to have a knee surgery. If your X-ray or MRI is negative, I still want to take a look at it after I have evaluated your knee. Sometimes there are changes that I am looking for that may be significant to me but not noted by the radiologist. It’s always good to have more than one eye look at any radiographic study.
Degenerative changes are not equivalent to arthritis and not necessary a cause of pain. Your pain needs to be correlated with any changes on MRI, X-Ray, or Ultrasound (US). Sometimes, the reason for your pain cannot be seen on these studies, such as nerve or fascia injuries. Sometimes tears are too small to be seen by X-ray or MRI, but can be seen by US. WE can evaluate an area, as it is moving. This is called dynamic imaging. This concept is so important to understand because some of the treatment options that are offered regularly won’t treat the issue and have proven to be harmful in terms of preserving the knee joint.
The normal process that occurs when someone has pain is to go to their Primary Care Physician, who refers them to Orthopedics or Physical Therapy. In the Orthopedic office, you may see the doctor or a physician assistant. In most situations, X-rays are done before the provider even evaluates you. This increases their efficiency, however, it may lead them down a pathway before they have interviewed you. The primary goal of the visit is to determine whether or not you are a surgical “candidate”. If you are not, injections with steroids or visco-supplementation (ie: Synvisc) may be offered. Physical Therapy or braces are other options.
Steroids have been shown to cause quicker degeneration of the cartilage, progressing to arthritis faster. There are studies that have shown this, yet their use continues to be prevalent even among well-trained physicians. Steroid injections have an effect outside of the joint. They caused my patients with diabetes to have elevated blood sugars for weeks after their injections. They increase the risk of infections, cause ulcers of the stomach, weaken bones leading to osteoporosis, cause sleep disturbances, increase peoples appetite, cause skin discoloration, and lead to dimpling of the skin after the fat beneath it atrophies. Steroids can cause your body to stop producing cortisol, a hormone produced in the adrenal gland, leading to fatigue, weight gain and a host of other symptoms. In general, the use of steroids either as an injection or in the form of pills is overused and is harmful. When administered, steroids are typically coupled with lidocaine or another anesthetic.
These too are harmful to the cartilage in the joint, as the pH is extremely acidic. It is important as a well-informed patient or a patient advocate to not pursue these treatments if your goal is to preserve the joint and avoid knee replacement.
Meniscus surgery has also been found to be harmful for the joint in the long run. The meniscus sits between the two bones of the knee. One of its functions is to guide the curved femoral condyles over the flat tibia. It also functions as a shock absorber. When portions of it are removed, the articular cartilage, which covers the bone becomes exposed to the articular cartilage below. Once the cartilage is damaged, there are a number of inflammatory markers that are released in the joint. Some are trying to protect the joint and others cause further destruction of the cartilage. Once the cartilage is destroyed, the term bone on bone arthritis is used. If your goal is to preserve the joint and avoid knee replacement, avoid meniscus surgery.
The knee joint has so many different structures around it that help support it. Ligaments attach from one bone to the next. Tendons attach muscles to bones. Fascia is a thin strong web of fibers that encase, envelop, or overlap most other structures and link the head bone to the toe bone. Together, these structures create a 360 degree compressive effect across the joint to prevent the bones from touching each other. This concept of intertwining fibers, effectively act like the basket weave of a Chinese Finger Toy. If you pull your fingers apart, the Chinese Finger Toy gets tighter. If you push your fingers together, the sidewalls of the toy collapse. It is an injury to the structures surrounding the joint that cause the joint to collapse. This alters the movement of the joint. When it moves abnormally, one area of the joint may rotated or slide abnormally, creating an abnormal wear pattern of the cartilage. This leads to arthritis.
If the goal is to preserve the joint, we need to correct the biomechanics or movement pattern of the joint. This is done by treating the ligaments, tendons, fascia, and nerves with a number of the injections that I do in the office. As they heal, after a series of multiple injections, the structures start to tighten. The functional joint alignment improves. Pain usually drops. Physical Therapy is also necessary, correcting the movement pattern. The joint is also treated, so that the environment within the joint improves and your body can attempt to fix or heal the injured cartilage.
There are 3 concepts to take home from this article:
1) The pain needs to be correlated with X-ray, MRI or Ultrasound studies
2) You need to be your best advocate when treatment options are proposed that can be harmful.
3) When treated, the many structures that support the joint and the joint itself need to be treated.