The knee is a hinge joint that is made up of bones, ligaments, muscles, and tendons. To give the joint stability, the bones are shaped to fit each other and are connected by ligaments on the inside and outside of the joint. Tendons are what connect the muscles to the bones, and the muscles are what provide movement to the joint. Between the two leg bones, the femur and the tibia, there are two pieces of cartilage on the upper and lower part of the joint, and in between the bones is another type of cartilage called the meniscus. When any of these areas are injured, it can cause pain and mobility issues in the joint.
When someone talks about the knee, we all have a pretty good idea of where it is located. When it comes to issues like knee pain treatment, it can be more complicated than it may seem at times. There are different issues that can cause pain in the knees. Prior to discussing treatment, it would be useful to have some background knowledge of the knee itself.
Overview of Knee Treatment
It is important to understand that the knee is a complex joint that plays an integral role in various activities ranging from simple function to more rigorous activities, such as walking, running, sitting, and standing. Proper understanding of the functionality of the knee and available treatment options is imperative for the healing of the condition and prevention of further complications. There are multiple knee conditions that are common to all ages, with the most common knee injury being an Anterior Cruciate Ligament (ACL) injury. This is a major injury in the knee which usually occurs in people who are involved with sports such as netball, basketball, soccer, and tennis. This is because the ACL is a ligament that connects the femur to the tibia at the knee joint and it helps to provide stability to the knee. The injury is usually a result of a sudden stop in movement or change of direction, or a pivot in the knee. This kind of injury would require Arthroscopic ACL reconstruction surgery. Other conditions include meniscal injuries, ligamentous injuries, tendon injuries, arthritis, or dislocation of the kneecap. With understanding the knee condition and treatment options available, following the best possible treatment will result in the best possible outcome.
Importance of Knee Health
Importance of knee health is more than often overlooked. It is only when issues arise that we truly recognize how much stress the knees go through every day. The knee is the largest joint in the body and it is made up of four main things: bones, cartilage, ligaments, and tendons. Imagine if just one of these were to fail or begin to give a person trouble. Simple tasks such as walking, going up or down stairs, or participating in physical activities would become a challenge and maybe impossible to perform. Over time, any person can incur a knee injury. Whether through trauma development or wear and tear, the knee is a common location for pain and discomfort. Anyone at any age can experience a knee problem. That is why it is pertinent to take the necessary steps to prevent a knee injury or to find the appropriate treatment if a problem arises. With the significance of the knee joint in mind, focusing on health and prevention of knee problems is essential for everyone.
Non-Surgical Knee Treatments
Physical therapists provide exercises to strengthen the leg muscles that support the knee. Strong muscles help the knee absorb shock more effectively. By absorbing shock, the knee is at decreased risk for future wear and tear. Coordinated exercises can help keep the knees in line, reducing further damage to the cartilage. Stretching exercises can help increase the range of motion of the knee. Physical therapy programs are generally individualized, taking into consideration the patient’s condition and lifestyle. Patient compliance is an essential aspect of the therapy, for it can influence the effectiveness of the program. On average, full recovery can be made in 2-4 months. The patient may also be instructed to conduct exercises at home. If the patient chooses not to undergo surgery, exercise has been shown to have benefits for those with meniscal and osteoarthritic knee conditions. In a study by K.L. Bennell et al., it was shown that participants with osteoarthritis who received exercise therapy had less pain and better function compared to those who received usual medical care.
Physical Therapy
Physical therapy is used to improve the strength and flexibility of the muscles and tendons surrounding the knee. It will enable the knee to better withstand the forces going through it. When the forces are reduced through activity modification and the muscles better control the forces going through the knee, the result is less pain and slowing of the degeneration process. Lastly, weight loss can significantly reduce pain and disability from osteoarthritis. A recent study that was reported in the December 31, 2005 issue of the American College of Rheumatology demonstrated that an 11-pound weight loss decreased the risk of developing symptomatic osteoarthritis of the knee by 50%.
Isotonic exercise involves movement of the joint and a change in the muscle length. This is the most effective form of exercise because it exercises the muscle throughout the entire range. There are two forms of isotonic exercise: concentric and eccentric. Concentric exercise involves the development of tension in a muscle as it shortens. Eccentric exercise involves the development of tension in a muscle as it lengthens. This is very important in muscle coordination and control of joint movement. Open chain isotonic exercises are those in which the distal segment of the joint is not in contact with anything.
There are many different types of physical therapy interventions. Isometric exercises involve muscle contractions without movement. The muscle length does not change and the affected joint does not move. The purpose of isometric exercises is to maintain strength in the muscles when there is a medical or physical reason that movement should not occur. These exercises can be used to maintain strength in a muscle that is to be protected after surgery and in a muscle with an acute injury that is too painful to allow movement.
Physical therapy is used to improve the strength and flexibility of the muscles and tendons surrounding the knee. It will enable the knee to better withstand the forces going through it. When the forces are reduced through activity modification and the muscles better control the forces going through the knee, the result is less pain and slowing of the degeneration process. Lastly, weight loss can significantly reduce pain and disability from osteoarthritis. A recent study that was reported in the December 31, 2005 issue of the American College of Rheumatology demonstrated that an 11-pound weight loss decreased the risk of developing symptomatic osteoarthritis of the knee by 50%.
Medications for Pain Management
Knee pain can be so intense that it is difficult or even impossible to develop an effective exercise program. This is frustrating because lack of exercise can lead to further weight gain and increased pain. Medications can be used to break this cycle. The simplest and safest medications for mild knee pain are the nonsteroidal anti-inflammatory drugs (NSAIDs). These reduce both pain and inflammation. There are many types and brands of NSAIDs, often referred to as simply anti-inflammatory pills. Their prescription varies from 1-3 pills a day and some patients find that certain brands are more effective than others. Common brands include all medicines ending with the suffix “-profen”. A more recent user-friendly version of NSAIDs for knee pain is the development of NSAID creams or gel, which are rubbed into the skin over the painful area. An alternative to NSAIDs is the ingestion of 1-2 tablespoons of cod liver oil or fish oil a day. This is believed to work through the same pathway as NSAIDs and there is some evidence to support its efficacy.
Medications for Pain Management
Injections for Knee Pain Relief
Finally, viscosupplementation therapy uses hyaluronic acid, a natural component of synovial fluid. The injections are meant to break down and improve movement of the synovial fluid, possibly relieving pain and acting like a lubricant and shock absorber. This treatment is commonly used for those with osteoarthritis.
Platelet-rich plasma (PRP) injections use the patient’s own blood to try and heal the damaged tissue. Blood is taken from the patient and placed in a centrifuge that spins the blood to separate the platelets. The platelets are injected into the knee to release growth factors to stimulate and increase the number of reparative cells. This is an emerging therapy for chronic tendon injuries, acute ligament and muscle injuries, and osteoarthritis.
Hyaluronic acid is a gel-like substance that is a normal component of the knee. It acts as a shock absorber and lubricant. The injections are meant to improve lubrication and cushioning in the knee, and provide pain relief. Treatment can last from several weeks to years. These injections are for mild to moderate osteoarthritis.
Corticosteroid injections use a potent anti-inflammatory to decrease inflammation. The relief can last for weeks to months, and these injections can be repeated every few months. They are commonly used to treat osteoarthritis.
There are several options for injections to reduce pain and inflammation in the knee. There are four common types of knee injections: corticosteroids, hyaluronic acid, platelet-rich plasma, and viscosupplementation.
Surgical Knee Treatments
Partial Knee Replacement This is an alternative to total knee arthroplasty, it is less invasive and is bone sparing. It is a more conservative reconstructive surgery. It involves only one part of the knee joint being replaced. If the arthritis is only in the medial or lateral side of the knee, then only that side will be replaced. This will be done using metal and plastic components or biological resurfacing. The advantages of partial knee replacement in comparison to total knee arthroplasty is that the ligaments and nerves are preserved which ensure good function to the knee. The recovery times are shorter and there is less pain after surgery.
Total Knee Arthroplasty (TKA) This is a well established and successful operation for people with advanced arthritis of the knee. The aim of the surgery is to relieve pain and improve function of the knee. The damaged areas of the knee are resurfaced with metal and plastic components which are fixed to the bone. This is done by cementing the resurfaced components into place or allowing the bone to grow into the porous coating on the implants. The prosthesis will provide an articulating surface, which will relieve the pain, improve the alignment of the knee and improve the function of the knee.
There are several surgical knee treatment Singapore options to the problem of osteoarthritis. Many of these operations are relatively new and therefore the long term benefits are not known. The main type of operation is a knee replacement, which involves removing the damaged bone and cartilage from the surface of your knee and replacing them with a metal and plastic joint. This operation has a good success rate and can last for up to 10 to 20 years, depending on the level of activity of the patient.
Total Knee Arthroplasty (TKA)
Patients are given a general or regional anaesthetic. A general anaesthetic will put you fully to sleep, whilst a regional anaesthetic will block pain sensation from your legs. The surgeon will remove the damaged joint and place a metal, high-grade polymer or ceramic prosthesis (artificial joint) in the joint. The prosthesis will be shaped to allow normal movement of the joint. At the end of the procedure, the surgeon will close the wound with staples or clips and apply a dressing. Total knee replacement is a complex procedure and there are different methods and types of prosthesis. Your surgeon will decide which is most appropriate for you. This will depend on your age, level of activity, weight, and the shape of your knee. He will discuss this with you in more detail. Total knee replacement is a very successful operation. The prosthesis can be expected to function well for at least 15-20 years in 90-95% of patients. After this time, it may become loose, painful, or infected. A revision joint replacement may be possible if there is still good bone left in the joint. This is a further operation which can be quite complex and may not achieve as good a result as the primary replacement.
Partial Knee Replacement
Partial knee replacement has a quicker recovery period than total knee replacement, as the surgeon will be able to work with the healthy ligaments and bone in the knee joint. Because the surgery is less invasive, there are fewer complications, less pain, and swelling at the incision site is gone after 2-3 weeks. A less invasive surgery also means that bone is preserved. For a more or less healthy individual, reduction in bone stock from a total knee replacement can lead to future reconstructive surgeries and, for the very elderly, fragile, or disabled, a fracture. Though revision surgeries are being done with increased success rates, it is best to avoid them whenever possible. The small incision or hole made to perform an arthroscope with this surgery causes minimal scarring, with a possibility of it not even being over the knee joint. Scarring on top of the knee can prevent future arthroscope surgeries if they are needed. Partial knee replacement can prolong the onset of degeneration in the other compartments of the knee, meaning that failure of this surgery and conversion to a total knee replacement can still provide a longer-lasting solution to knee joint degradation compared to having initially opted for a total knee replacement.
The patient suitable for partial knee replacement should be over 55 years old and less active compared to younger patients who have total knee replacement (TKR). Candidates are typically not overweight, have pain predominantly in one compartment of the knee, are able to walk comfortably without aid, and have an intact or stable anterior cruciate ligament (ACL). ACL damage leads to abnormal functioning of the knee and is often associated with injuries that require surgery, making it a contraindication for partial knee replacement. It is useful for patients with degenerative arthritis, osteonecrosis, and post-traumatic arthritis who have failed non-operative treatments. Osteoarthritis patients are the best-served group.
Partial knee replacement is a surgical procedure indicated for patients with severe destruction and disability in one or two compartments of the knee. This surgery effectively replaces the knee joint surface. It is not simply a quick fix or transitional surgery for the knee, but a holistic approach to resolving knee pain for the rest of one’s life.
Arthroscopic Knee Surgery
The recovery from arthroscopic knee surgery is generally quicker than that from traditional open surgery. The procedure usually involves postoperative physiotherapy, which is in most cases already commenced. In more simple procedures, the patients may be able to use continuous passive motion machines as a self-administered treatment. Often this is the case in the treatment of swelling and pain of the knee joint. This can have great benefit to rheumatoid patients and also to osteoarthritis patients, who often would produce more swelling and pain following more complex surgical procedures. Overall, the most substantial benefit of arthroscopic knee surgery is the ability to use it as a diagnostic tool and also the ability to carry out a procedure. The extent of this has significant growth potential and has proven to be a very important procedure for the treatment and diagnosis of knee problems.
Surgery Arthroscopy Currently selected. 3.3 Arthroscopic Knee Surgery Arthroscopic knee surgery is a useful approach for the treatment of several knee problems. The procedure is literally ‘minimally invasive’, involving only small incisions to the knee and sometimes requiring no incisions at all. Out of all types of knee surgery, arthroscopy has become the most commonly performed procedure for the treatment of the knee. The procedure involves the use of a viewing scope to diagnose and treat a knee problem. The scope is known as an arthroscope and contains a small camera which is used to project images of the inside of the knee onto a computer screen. This allows the surgeon to have a clear and detailed image of exactly what is happening inside the knee and thus can pinpoint the problem. After the problem has been located, the surgeon is able to use small surgical instruments to carry out the repair of the knee. Usually, this is done without the need for ‘open’ surgery, hence reducing the trauma to the connective tissue in the knee and possibly leading to a quicker recovery. A number of knee problems can be treated using arthroscopy, with some of the younger population considering the reconstruction of a torn ligament. The goal of such a procedure is to restore normal stability to the knee and prevent the early onset of arthritis. Recommended Image: Arthroscopic knee surgery involves the use of an arthroscope in combination with a monitor to view the inside of the knee. (click to enlarge)
Arthroscopy can be used to treat different types of knee conditions, e.g., unexplained knee pain or to collect information on the extent of a knee injury. Evidence suggests that the procedure is overused in older patients with degenerative knee changes. On the other hand, situations in which the procedure may benefit patients, e.g., mild/moderate knee arthritis with a meniscal tear, the procedure has been shown to improve quality-adjusted life expectancy and offer value for money. Although in many cases, arthroscopic knee surgery appears to be the most cost-effective management.
Arthroscopic knee surgery has revolutionized the treatment of knee injuries. In the past, patients would undergo long incisions causing significant damage to the surrounding tissue and necessitating a longer recovery time. Traditional knee surgery often required a hospital stay, and even after was a painful and slow road to recovery. However, arthroscopic knee surgery has changed that. With only a few tiny incisions, a camera, and small surgical instruments, the surgeon is able to operate with great precision. High-quality images are displayed on a screen, allowing the surgeon to see and work in fine detail. The technique for the surgery is often relatively quick, and with the small incisions, the patient does not have to spend a long time in the hospital. After the surgery, the affected knee is often rested for a short period of time, followed by a fairly quick recovery and outpatient physiotherapy. This form of knee surgery is often used for the treatment of meniscus and ligament injuries.
Rehabilitation and Recovery
Rehabilitation is a crucial process to regain knee strength and stability. Its duration and course of exercises may be different for individuals, depending on the type of surgery, the specific knee problem, and the individual’s overall health. Rehabilitation is about regaining strength, flexibility, and endurance while returning to a more active lifestyle. A typical rehabilitation program includes an extensive home program, as well as outpatient physical therapy. The first few days or weeks may require the use of crutches or a brace for support. Initial rehabilitation will focus on flexibility exercises and restoration of motion. This may begin with a continuous passive motion (CPM) machine. The patient generally goes to physical therapy for 2-4 months, although this can vary depending on the extent of the rehabilitation that the patient needs. The patient will work on increasing knee strength and motion during this time. The final phase of rehabilitation is aimed at a gradual return to activities that do not require pivoting or high knee stress. This would occur at approximately 6-7 months post-operative. It will often be customary for the individual to wear a knee brace for protection during this time. At approximately 9-12 months post-operative, the patient will work on a gradual return to more demanding activities, while continuing knee strengthening exercises.
Post-Surgery Rehabilitation
Physical therapy is essential to your recovery. Your therapist will work with you to increase your range of motion in your new knee and decrease swelling. You will be given several exercises to perform on your own which will increase your strength and mobility. It is important that you perform these exercises as prescribed by your therapist. Using your new knee to do too much too soon can be harmful. Your therapist may also utilize other treatment techniques including electrical stimulation, or application of hot or cold packs to help relax muscles and decrease pain and swelling. Usually the physical therapy regimen will last for 4-6 weeks, but it varies depending on a patient’s progress.
Successful post-surgery rehabilitation is integral to your knee replacement recovery. Your rehabilitation programme begins almost immediately after your surgery. A physiotherapist will teach you specific exercises to help strengthen your new knee and the other muscles of your leg. Other exercises, such as marching or riding a stationary bicycle, are sometimes used to strengthen your knee. You will be given a list of “do’s and don’ts” to remember with your new knee. This will include body positions to avoid, how to properly use an assistive device, and the importance of taking care of your new knee. You will be discharged home or to a rehabilitation facility with a plan for your return to normal activities.
Managing Pain and Swelling
Following surgery or in a program of rehabilitation, the first few exercises are designed simply to regain control of the quadriceps. The following progression of exercises will safely bring your quadriceps muscle back to its full function. We must caution that you should never be in pain during or after doing any of these exercises. If you should have pain, either at that time or any time during the rest of the day, go back to the previous exercise and stay at that level until you are able to progress without pain. In time, when you are able to do all the exercises with virtually no symptoms, you can protect your knee with a brace and begin your normal sports activities. Continue these exercises even after you have returned to your activities for as long as you have swelling. Remember, it is the control of the thigh muscle that will stabilize the knee and prevent re-injury.
Exercises for Strengthening the Knee
The most important aspect for a successful recovery following knee surgery is to strengthen the quadriceps muscle. These muscles often weaken after knee surgery, injury or prolonged inactivity, and it is therefore important to re-strengthen them in order to support the knee and increase stability. Straight leg raises, short arc movements and quadricep contractions all help to strengthen the quadricep muscles. Hamstring curls (using a resistance band or machine), also help to improve the strength of the hamstring muscles at the back of the thigh, thus improving balance and support for the knee. Step-ups are also an excellent exercise to strengthen the quads, glutes and hamstrings and increase overall leg strength. Stand facing a step, box or bottom stair. Place the surgical leg on the step and the good leg on the floor. Straighten the surgical leg so that the good leg comes off the floor and tap the good leg on the edge of the step. Do two sets of 15 repetitions. Although this exercise needs to be approached with caution and discussed with your physiotherapist or surgeon, cycling is also an excellent form of exercise to help to strengthen the knee and leg muscles. Static cycling is a good place to start, and once confidence is gained and strength improves, progress to low resistance level on an exercise bike. A forceful but smooth revolution with a full cycle of the pedal helps to improve muscle strength and endurance.
