You probably have experienced it at some point in your life, climbing down a flight of stairs, after a long trail run or after a fall. The much-talked-about and much-dreaded phenomenon known as knee pain is at once the bane of athletes gearing up for competition, the infrequent visitor for most of us and also the daily companion of many elderly folks.
Even though it is such a common occurence, many people still have misconceptions about knee pain and few people actually know what is the best thing to do with a painful knee. Most people have some idea, an overwhelming majority depend on hear-say and previous experiences, and some will just leave it alone and hope it goes away on its own. Most of the time, the pain does indeed go away after a period of rest, but what happens if it does not or if it keeps coming back. What do you do?
The problem with the term “knee pain” is that it is all-encompassing and so frustratingly non-specific. The knee is a fairly complex structure of our body comprising of numerous ligaments, tendons, muscles, nerves, a few bones and many separate cartilaginous structures in many layers crisscrossing everywhere. All these structures are potential causes of knee pain and very often do cause problems. If you flip through any orthopaedic or sports medicine textbook, there is a list of at least 50 different diagnosis for knee pain alone, all very different in treatment and outcome. Given that most people will have insufficient experience with this bewildering spectrum of knee pain, should one take painkillers and rest, wear a brace and carry on or take glucosamine and hope for the best?
While it is not possible for most people to understand the intricacies of knee injury or knee pain treatment, it is very possible to alleviate the pain and problem while seeking medical attention, and more importantly to do the right thing so that the injury does not worsen. I have recently seen a rise in the number of people with aggravated knee injuries largely due to mismanagement.
In this article, I will go through some of the principles and strategies in first aid treatment of knee pain until a proper assessment by a professional is obtained. I will also briefly touch on some of the products marketed for knee problems and pain and some of the things that one might encounter in the doctor’s or therapist’s office.
RICE – Rest, Ice, Compression, Elevation
This is probably one of the most commonly employed techniques by athletes, active people and those with acute injuries. It is a good immediate treatment for almost all sports injuries and musculoskeletal injuries. If there is a knock, fall, trauma or forceful contact with subsequent pain, swelling and redness, RICE treatment is always very helpful and it will reduce the overall swelling and rest period for that injury. RICE can also be used on sudden knee swellings from various inflammatory causes. It is generally more useful for acute injuries not as useful in chronic or recurrent knee pain.
Icing is commonly done in the first 24-72hrs after injury, and depending on the severity and size of the injury, it can be done every 4-6 hourly. The ice pack should not be in contact with naked skin and the icing time (ice pack wrapped in a towel) should be limited by the size of the body part in question, for the knee 15-20 minutes will suffice. Prolonged icing may cause frost bite injuries of the skin and tissues and lead to scarring of the skin or other complications.
Compression is useful and can be done with a compressive brace or a compression bandage. Compression helps to prevent re-accumulation of fluid in the joint and tissues and also helps to off-load stress from the injured structures. Elevation also relieves swelling in the tissues by action of gravity. When at rest, the knee should be higher than the pelvis or groin. It does not need to be elevated very much, 2 pillows below the heel of the affected leg will give sufficient rise to the knee. Rest is of course, self-explanatory, but in most lower limb injuries, it is difficult to achieve total rest as we are always on the move. Reduction of activity level, no strenuous activities and no impact or loading activities are usually all the “rest” that is required – it also means using the affected body part as little as possible, at least for the first few days after injury.
Pain killers (Paracetamol, Ibuprofen, Naproxen, Diclofenac etc.)
There are many different pain killers on the market and it may be quite bewildering to most people. One easy way to classify painkillers is to divide them into 2 categories, “Anti-inflammatories” and “Others”. Anti-inflammatories refer to a large class of related drugs that include ibuprofen (Bufen), naproxen (Synflex), diclofenac (Voltaren), aspirin, Celebrex and Arcoxia as some of the more commonly encountered ones. They work by reducing inflammation and pain associated with inflammation, hence the name and which is why they are usually limited to pain caused by trauma, contusions or inflammation, very similar to the injuries that respond to icing. Acute sprains and strains and knocks and swellings are all things that are likely to respond well to anti-inflammatories. Reducing inflammation in joints is important not only to reduce pain but also to reduce damage to the soft tissues – ligaments, cartilage, tendons, and it also reduces functional “downtime” .
The other large group of painkillers are painkillers that work by other mechanisms but generally affect the perception of pain itself by modulating nerve function. Common examples are paracetamol (Acetaminophen, Panadol, Tylenol) and their derivatives, codeine and their derivatives, tramadol, baclofen, gabapentin and many others. These work well for all kinds of pain, inflammatory and non-inflammatory pain such as those from nerve pain. But there is a huge variability of tolerance, efficacy and side effects from person to person. Non-inflammatory pain may come from many disorders such as fibromyolgia, myofascial syndrome and such but these conditions is rarely confined to the knee. Rheumatoid arthritis, Osteoarthritis, Gouty arthritis and other form of arthritis affecting the knee usually have an inflammatory component and will respond well to anti-inflammatories, but adding paracetamol or other non-anti-inflammatory painkillers may help to control the pain better. As a general guide, if the pain or swelling does not improve after 1-2 days of painkillers and medications, you will need to see a doctor to have it checked out. Do not take painkillers indefinitely and do not take more than the prescribed dose.
Muscle creams – Capsicin, Methylsalicylate creams
As the name suggest, these are mainly muscle rubs, meaning they act to relax the muscles and help to soothe the aches and pains generally cause by muscle strain and fatigue. Most of these creams contain methylsalicylate, menthol and/ or capsicin which provides a sensation of “heat” after application. They often cause redness over the skin when applied as these chemicals cause the capillaries of the skin to dilate and hence the “blush” – redness of the skin and the hot feeling. These creams are useful for sore, aching and tired muscles and it is thought that the heat has a direct effect in relaxing the contracted and tense muscle fibres and the dilation of the micro-circulation helps to clear out the waste products from the worked-out muscle. Recent research suggests that capsicin is slightly different in the way it produces its effects, it seems to act directly on nerve endings to reduce sensitivity to pain and at the same time induces the feeling of heat over the area. Although it may feel the same, the implications are quite different.
Methylsalicylate and menthol muscle creams are generally more useful over muscle areas where fatigued and strained muscles causes aching and pain whereas capsicin has been shown to be helpful in reducing pain in chronically painful joints. However it must be noted that capsicin only reduces the perception of pain but not necessarily the cause of pain and it requires regular use over a few weeks to reach maximal effect and continual use for sustained efficacy, hence it is probably more useful in end-stage joint disease or chronic pain syndromes with a neurological cause.
Glucosamine, Chondroitin, MSM, Collagen (“Cartilage replenishment therapy”)
Until recently, glucosamine was one of the most popular supplement products found in any health, supplement, and nutrition stores. It was also one of the most commonly used supplement products by the public together with calcium-based supplements and vitamin C-based supplements. This popularity can be attributed to a spate of studies and trials from the 1990s and the early-2000′s which showed that glucosamine was helpful in reducing pain in osteoarthritic joints particularly the knee joint. Furthermore a few trials during that time also showed or suggested cartilage healing in these degenerate joints spurred the media to trumpet it as the “wonder-drug” for old age and a boon for all baby-boomers. As of this year 2010, because of several well-publicised reports that questioned the efficacy of glucosamine and called into question the amount of bias in earlier studies, public opinion of glucosamine has largely swung towards the opposite spectrum. So is it time to throw out your yearly supply of glucosamine and start demanding a refund?
In the first place, if more people had understood what glucosamine was all about, there would have have been less people buying into the hype. These days there are many people who have taken glucosamine for all kinds of joint pain simply because it “works for their friends”. This is how I explain the efficacy to them: Glucosamine does have some effect on painful knees, but it works only for knee pain from cartilage problems. Furthermore it does not work for everybody, it works for roughly 1 in every 2 person taking it, and it must be taken over a couple of months before the pain-reduction, if at all, is significant. Most importantly it should not be seen as the only “treatment” needed for an arthritic knee. Once glucosamine is stopped for whatever reason, the effect also wears off in a few months and the pain returns. That makes it sound like a painkiller, a slow-acting, chancy painkiller but still a painkiller nonetheless. So I always find it funny when patients who refuse to take any painkillers but are so keen on taking glucosamine supplements. Hence glucosamine and its ilk, such as chondroitin and collagen, can be taught as pain-relieving therapies. While there is evidence to show that these substances do have some effect in supporting and repairing damage cartilage (but cartilage will heal naturally even without the supplements), merely looking at the cartilage damage and repair is missing the whole point about osteoarthritis or joint degeneration. Although cartilage degeneration is a hallmark feature of osteoarthritis, it is the end product of the whole degenerative process, not the cause of it. If our treatment targets only the end-product without actually modifying the cause and disease process, such as glucosamine does, then it is no wonder that for all that glucosamine consumed, there have been no drop in the rate of knee replacement surgeries done in the past decade.
But is glucosamine, collagen and its ilk without its uses? Not entirely, I still prescribe them for my patients but I generally reserve them for the patients with end-stage joint degeneration where the aim is to prolong the use of their joints for as long as possible before joint replacement surgery. For this group of people, treatment is geared towards pain management and preservation of joint function, hence this will be a valid cost-effective therapy. And even for this group of people, cartilage-replenishment therapeutics are never the only treatment we will institute. Rehabilitation, self-management, education and exercise are still the main-stays of treatment. Other pain management methods such as physical therapy modalities, acupuncture and anti-inflammatories and other painkillers can also be helpful. For everyone else, if you want to take glucosamine or collagen, that’s fine. But my recommendation is that you don’t rely on just that, because it is highly unlikely that these supplements alone will save your knee.
Injections – painkillers, H&L, steroids and hyaluronic acid
Most people would be familiar with painkiller injections given at some point in their life either in the shoulder or buttock to relieve pain when they see a doctor for severe pain. The medicines given are usually injectable forms of anti-inflammatories we talked about earlier – the most commonly used being diclofenac or Voltaren. The medicine is absorbed into the blood stream and works on the affected body part to control pain and curb the swelling and inflammation associated with the injury. But there is also another kind of injections that some people may have experienced – intra-articular injection or injections directly into the joint.
Injections into the knee joint would usually be of 2 types – the steroid injections and the “gel”-type of injections. The former refers to what doctors would term “H&L” or “Hydrocortisone and Lignocaine” injections but this is a misnomer as nowadays nobody uses hydrocortisone for intra-articular injections. What is used are other steroids such as triamcinolone and betamethasone. Lignocaine, a local anaestheisa, is added to temporarily blocks the sensory perception of nerves and hence block the sensation of pain. How this particular injection works is that it helps to reduce local pain and swelling but it also works over a prolonged period of weeks to months due to the action of the insoluble steroid suspension. Hence this is a treatment more favoured towards chronic or recurrent inflammatory conditions but this particular therapy has also fallen out of favour in recent years, not because it is ineffective but because there are several important limitations and problems with the injections. One of which is inherent to all painkillers is the age-old conundrum of treating the pain but not the problem, especially in joints and muscles where pain is sometimes a good thing pain discourages greater use of the injured part which helps protect against worsening of the condition. The other concern is that locally injected steroids have been shown in some recent studies to temporarily weaken connective tissues such as tendons and ligaments which may predispose to further injuries with continued use in the weakened state. Again this a useful treatment in certain chronic or recurrent inflammatory knee conditions that has to be used with certain care.
Intra-articular gel injections consist of injectable sterile hyaluronic acid as the main active component and are work similar to orally-taken glucosamine and collagen as it helps to bolster the production of cartilage and connective tissue supporting structure and the lubricating fluid – the synovial fluid – in the knee. Again this is a cartilage-replenishment therapy that works mainly as a painkiller or pain-reduction therapy. A typical course of these injections is 3-5 injections, once a week. It works in about 7 out of every 10 people and pain reduction for these people will be about 50-80% depending on various factors. It is however fairly expensive and its use should be limited to those with end-stage joint degeneration or in the context of a well-planned multi-pronged treatment.
So… What do I do if I have knee pain?
In summary, if one has acute knee pain – from a sports injury, sprain, strain, contusion, knock or a fall:
1. Wash the wound if there is an open wound, dress it with clean or sterile gauze if it is available.
2. Cover the wound and apply local pressure if there is bleeding, this will usually be painful but useful for stop or slow bleeding. If a fracture is suspected, do not apply pressure or treat further without guidance. Fractures should be stabilised and immobilised and medical attention should be sought.
3. If there is no bleeding or open wound or the above steps are done, apply RICE therapy – rest, ice, compression and elevation. This is generally useful for any red, swollen, painful and tender knee pain.
4. If you have some anti-inflammatories or painkillers that you have used before and are not allergic to, you can take the recommended dose before seeking medical attention.
5. If injury is severe or causes inability to walk or weight-bear on that knee or if pain does not improve or subside after 24hours or if pain worsens, you should seek medical attention as soon as possible.
For acute knee pain – which occurs suddenly without injury or trauma or activity:
1. This is likely to be an inflammatory problem or from an infection, medical attention is recommended especially if it doesn’t improve on its own after a day. Anti-inflammatories may help but in the case of an infection, antibiotics may also be required, and you will need a professional assessment to decide on the course of treatment.
For chronic knee pain or recurrent knee pain:
1. If you know what is the problem, either because it is a chronic recurring pain or a relapsing pain, then treat as per advice given by your doctor or specialist.
2. Any new pain that has lasted for more than a week or keeps recurring after more than 1-2 months should be brought to a doctor’s attention for assessment. The earlier treatment is sought, the better the outcome usually is and recovery is usually faster as well. Going for X-rays without an assessment can be a waste of time and money because the vast majority of knee pain does not originate from any bony problems, and x-rays is only reliable for detecting bony problems and injuries. It has other uses like assessment of biomechanical alignment but this is best interpreted by a specialist or someone trained to look at both x-rays and clinical function of a person.
3. Try not to doctor-hop or therapist-hop unless you are certain that the doctor or therapist cannot be trusted or you have serious problems believing what he or she tells you. Patients who do so give rise to a few problems for themselves as the next professional they visit may not have a complete picture of the problem and treatments done previously and may have to start all over again. Remember that the problem can sometimes change over time so what may look like a certain condition initially may not be the same after a while. Also remember that everybody is different, what works for someone may not work for you. It will thus help the doctor or therapist if they get the feedback to know what works or does not work for you. The third problem being if there is a prevalent culture of doctor-hopping or non-compliance, the doctor or therapist will only be able to treat your pain and not your problem because treating the underlying problems invariably takes more time and more compliance from the patient.
In many painful knees that I have seen, because of a preoccupation with treating the pain, whether due to cultural preference, lack of time or impatience, the knee usually ends up in a less-salvageable state. Remember pain is a symptom that something is wrong, and in most times it is not your enemy, it is your friend telling you something is not quite right and you need to fix the problem. Don’t kill the messenger for bringing bad news!
In Part 2, I will discuss and talk about some of the physical modalities and treatments that are used to treat knee pain and muscle and joint pain.
In Part 3, I will discuss more about osteoarthritis, cartilage degeneration and all that jazz about glucosamine, collagen and such. And what really works to preserve your knee.
