The significance of knee pain is beginning to be recognized in preventive and predictive medicine. Traditionally, the knee has been deemed a hinge joint necessary only for mobility and stability. Knee pain and its impacts were considered standard consequences of aging, and were largely addressed with pain-relieving medication and eventual joint replacement for those with advanced knee osteoarthritis. However, knee pain is now being understood in the context of its specific effects on quality of life and the implications of its long-term progression. This trend is supported by the current international movement towards patient-centered health and the recent development of reliable and valid clinical assessments of knee pain and its impacts.
The prevalence of knee pain, a predominant symptom of knee osteoarthritis, is increasing with a longer life expectancy and rising obesity in many developed and developing countries. Its impact on public health is substantial given the personal and socioeconomic burden of knee pain and its negative effects on physical function and quality of life. Knee pain, even in its mildest form, is associated with disability, and the resulting functional limitation can lead to social isolation, mood disturbances, and an overall reduction in health status. This has been clearly demonstrated in studies of knee pain and its effects on older adults, but it is also relevant to the general adult population and can lead to work disability and decreased productivity.
Understanding Knee Pain in Aging
Unfortunately, knee pain, despite its high prevalence, has been relatively neglected in health research compared with other musculoskeletal conditions and certain chronic diseases. This is especially true in the understanding of the non-traumatic causes of knee pain and its overall public health effects. An expert panel on knee pain and structural change has recently been convened by the World Health Organization. This is a worthy initiative, as the condition deserves more attention in health agendas and needs more powerful strategies for prevention and treatment.
Collectively, these findings suggest that we should be prepared for an epidemic increase in knee pain and osteoarthritis in the coming years and that it is an important condition to target with preventive strategies in the growing population of older people. Since knee pain may have dramatic effects on the lifestyle of older people and is a strong risk factor for the onset and progression of knee OA, understanding its etiology and direct effects on health is important for clarifying the role of preventive actions.
An American study on the prevalence of knee pain in the population showed that 25% of those aged 56–91 years responded that they had experienced recent knee pain. This was much greater than that reported by people of the same generation surveyed 20 years earlier. Substantial increases in the recent use of healthcare for knee pain and symptomatic knee OA have also been shown in the last decade.
Knee pain is a common issue in wealthy countries. It is associated with multiple risk factors, including being overweight or having been overweight in the past, occupational factors (particularly regular stair climbing), and the presence of co-morbid diseases. Its incidence and prevalence also increase with age, even after taking into account the higher risk of knee injuries in the young.
Impact of Knee Pain on Daily Life
As knee pain poses a hazard to the traditional independence older adults cherished in their peak, it is not shocking that it contributes to a lower quality of life. Those affected by chronic knee pain often adopt a more sedentary lifestyle, which further contributes to a loss of function, deterioration in the muscles supporting the knee, and more weight gain. With the aim of not exacerbating the pain, those affected tend to avoid activities that involve the utilization of the knee. By doing so, it causes the leg muscles to atrophy and become further weakened – an example of disuse syndrome. It was identified by a SGH interdisciplinary team that the majority of the patients they interviewed had frequent difficulty in the performance of activities of daily living (ADL) and instrumental activities of daily living (IADL). Improvement of knee pain could result in fewer lost working days, less assistance required whether financially or physically, and even the prevention of depression, which is often associated with chronic pain. Step down the list for more details about Knee Pain and Depression.
Managing Knee Pain
Non-Surgical Treatment Options
Bracing is rarely helpful in isolation, and the majority of patients with significant structural abnormalities will eventually require surgical intervention.
Injections of corticosteroid into the knee joint are useful to treat acute exacerbations of pain and swelling. Viscosupplementation with intra-articular hyaluronic acid is a controversial but relatively safe treatment to improve symptoms in patients with mild to moderate osteoarthritis. A small number of patients may benefit from joint lavage and debridement for mechanical symptoms.
Paracetamol is recommended as the first-line oral analgesic medication. The use of non-steroidal anti-inflammatory drugs (NSAIDs) should be weighed against potential side effects, especially in elderly patients. These medications are particularly useful following an acute exacerbation of pain. Topical NSAIDs offer an alternative with reduced systemic absorption.
Non-surgical treatment options, including physiotherapy, medications, and injections, are often useful for amelioration of symptoms. Physiotherapists can teach exercises to help strengthen the quadriceps and hamstrings and stabilize the knee. Efforts to avoid aggravating activities and modify lifestyle factors, such as weight loss, can be very important in the long term. Patient education is the most important aspect of self-management, and advice to stay active and function normally is essential.
Surgical Intervention for Knee Pain
The categorisation of patients who decide to undergo surgery includes those who have mechanical symptoms such as catching or locking, and/or X-ray evidence of damage to the joint. Arthroscopy or keyhole surgery is useful when patients have a torn cartilage and the surgeon feels that it is repairable. Unfortunately, it is difficult for patients to know if their knee pain is coming from the cartilage, as similarly degenerative arthritis can cause similar symptoms. In general terms, if there is evidence of mild or moderate arthritis alone, arthroscopy is not considered to be an effective treatment. An exception to this may be when there is a mechanical symptom coming from displaced or loose cartilage due to the arthritis, provided that there is good evidence that the mechanical symptom is what is causing the pain. Stepwise progression of osteoarthritis frequently results in advanced ‘bone on bone’ changes in the knee joint. This situation can be effectively treated with a high tibial osteotomy, which is a surgical procedure that involves realignment of the knee. This is often recommended in active patients who are still too young to consider joint replacement, and it has been shown to provide a considerable delay in the need for joint replacement to be performed. Joint replacement is established as an effective surgical treatment for knee arthritis, with excellent outcomes in terms of pain relief and improvement in function. This is demonstrated in the substantial and increasing number of knee replacements being performed each year in Singapore. As our population continues to age and increasingly demand high levels of physical function, knee joint replacements will become even more frequent. This is in great contrast to the situation in the past when joint replacement was predominantly performed in older, lower demand patients. The increasing numbers of joint replacements being performed in younger and more active patients has led to two problems: the first is the need to increase the overall lifespan of the knee replacement as it is expected to wear out, thus there is ongoing research into the best materials to use for joint replacement with the hope of decreasing adverse effects and increasing the lifespan of the implant. The second is a trend in patients with early knee arthritis considering joint replacement as a definitive treatment. An example of this is the increasing numbers of joint replacements being performed in patients aged between 40-60. This is a concern, as although it is a tempting proposition for these patients who are looking for an effective and permanent cure for their pain, joint replacement in a relatively young patient will simply shift the burden of more complex revision surgery to a later stage in their life. This is an important consideration when coming to the most invasive surgical treatment for knee osteoarthritis and its potential implications both in an individual patient and on a societal level.
Rehabilitation and Physical Therapy
Physiotherapy with modalities is a common practice, but their therapeutic effect has not been proven. Transcutaneous electrical nerve stimulation (TENS) is useful for some patients. There is good evidence to show acupuncture is effective in the treatment of arthritis. This involves the insertion of fine needles on specific points on the body for pain relief or for other therapeutic purposes. A recent randomized controlled trial has shown significant pain relief and improvement in function in patients who had acupuncture done, as compared to those who had sham acupuncture. However, further research is required to determine the location of application, the frequency of application, and the mode of action in the long term.
Rehabilitation and physical therapy form the backbone of management for symptomatic knees, irrespective of the age of the patients. The principal goal of rehabilitation is to decrease pain and swelling and to regain full movement of the knee. It is also aimed at strengthening the muscles around the knee and may be supplemented by a brace to take load off the affected compartment of the knee. Failure of strengthening of the quadriceps muscles has been shown to predispose to progression of arthritis in the knee. A systematic review has shown that exercise therapy is effective at improving pain and function in patients with knee osteoarthritis and is recommended for all patients. This effect is augmented when the therapy is supervised by a physiotherapist, and it has been shown to be just as effective when there is individual therapy as opposed to group therapy.
Finding a Knee Pain Specialist
The Physiotherapist specializes in diagnosing and treating musculoskeletal problems. Orthopaedic surgeons are surgeons who specialize in operating on the musculoskeletal system. A Rheumatologist is a doctor who specializes in diagnosing, treating, and medically managing patients with arthritis and other musculoskeletal diseases. A Sports Physician specializes in treating sports injuries such as ligament and meniscal tears. Depending on the severity of your knee pain problem, you would be able to choose which specialist to consult for your knee pain problem.
There are a few different types of knee pain specialist in Singapore who you can consult for knee pain problems. Choices include General Practitioners, Orthopaedic Surgeons, Rheumatologists, Sports Physicians, and Physiotherapists. The GP is usually the patient’s first point of contact. He/she will take a history of your knee pain problem and, coupled with a physical examination, would be able to diagnose the problem in most cases.
Knee pain problems vary in severity from patient to patient. However, you should seek medical treatment from a knee pain specialist if your symptoms are not getting better or are getting worse in a 2-week period. A knee pain specialist is a qualified medical professional who is an expert in diagnosing, treating, and preventing knee pain problems.
Available Treatment Facilities in Singapore
Singapore has a number of healthcare institutions providing excellent medical care for arthritis. These institutions serve to provide accurate diagnosis, up-to-date treatments, and management strategies for arthritis to help patients attain pain-free and improved function in the affected joints. Management of arthritis conditions often involves a multidisciplinary approach. Treatment modalities include medication, non-pharmacological interventions, surgical interventions, or a combination of any of these. Patients with inflammatory arthritis and complex autoimmune systemic diseases also benefit from rheumatology services at these institutions. These services may also extend to an outpatient day treatment setting and inpatient services for more severe cases. A list of institutions and their respective services is compiled below.
