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The Science of Knee Pain: Expert Perspectives from Singapore

As you get older, you are more likely to experience knee pain. This is because your joints degenerate over time. Osteoarthritis is a common condition in older people and it causes a great deal of pain in the knees. The second most common condition is rheumatoid arthritis, which can affect any age group. It is an autoimmune condition and it affects the membrane which surrounds the joint. This can lead to severe pain and, if left untreated, can hinder mobility. Another common condition in the older generation is gout. Gout is caused by the build-up of uric acid, usually occurring in people who are overweight. This uric acid is deposited into the synovial fluid of joints and causes extreme pain and inflammation. An affected knee can become swollen, red, hot, and very tender to touch. This pain is renowned as being very severe, and it can hinder movement.

The knee is one of the largest and most complex joints in the body. It is built to sustain a considerable amount of pressure and stress from the activities in our daily lives. In some cases, unfortunately, it can sometimes suffer pain and injury from sudden movement or an existing condition. One of the most common problems is knee pain. The knee pain can be localized in one area of the knee or diffused throughout the knee. Due to the nature of the knee, it is easily injured. It is also very prone to afflictions of osteoarthritis and inflammatory diseases. Usually, knee pain is a symptom of an underlying condition or injury. There are many types of acute or sudden injuries that can cause knee pain or overuse conditions which can lead to pain.

Understanding Knee Pain

The muscles of the leg are responsible for movement and stability of the knee. The quadriceps and hamstrings muscles provide the power for movement and also act as stabilizers. The muscles on the medial and lateral part of the knee control the alignment of the knee and the forces acting upon it. Any injury or disease to the above-mentioned structures can lead to pain and cause difficulty with daily activities.

In order to understand why knee pain occurs, it is important to understand how the knee works. The knee is a hinge joint that is held together by the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL). The joint surface is covered by articular cartilage, which provides a smooth gliding surface. Between the bones, there are two layers of menisci, which act as shock absorbers that help stabilize the joint.

Understanding knee pain is important. It is most commonly activity-related. The knee is susceptible to injury and the development of osteoarthritis. At any age, the bone structure may be susceptible to injury or disease. However, persistent knee pain that is not due to traumatic injury often has to do with poor body alignment. This includes the way the bones are aligned, how the muscles are working, and the distribution of body weight.

Common Causes of Knee Pain

Damaged cartilage – the most common cause of knee pain. There are a lot of types of cartilage: the meniscus, articular cartilage, and patella cartilage to mention a few. Damage can be caused by a sudden incident, like a sports injury, or gradual wear and tear. Eventually, there may be some loose body in the knee. While every knee injury is anatomically unique, all variables who have knee pain are too common that most of knee pain from wear and tear do lead to arthritis. In knee pain Singapore, the most common knee injury is a meniscus tear. This C-shaped wedge of cartilage will act as a cushion between the thighbone and shinbone. A twisting motion has often been referred to as the cause of the sudden meniscus injury. Older people will tend to get degenerative meniscus tears as the cartilage weakens with age. Deep knee pain, swelling, joint line tenderness, and difficulty extending the knee fully are symptoms of a meniscus tear. Osteoarthritis – a slow and progressive cartilage loss. Arthritis affects millions of people and is the second leading cause of chronic knee pain. “Wear and tear” is a common term used for osteoarthritis. It’ll affect the weight-bearing joints like the hips and knees. Osteoarthritis usually begins in the 50s and 60s, but it’s not rare that people in their 30s and 40s develop osteoarthritis. In a society where people are getting more educated, patients are often aware of their condition as they show up to the clinics and request x-rays to diagnose if they have arthritis or not. Osteoarthritis is a slow and progressive cartilage loss. The term degenerative joint disease is essentially describing osteoarthritis. As the cartilage thins, the underlying bone develops increased density. Large, weight-bearing osteophytes develop as the bone tries to remodel a stronger surface. Unfortunately, the cartilage will never be restored to its original state. Symptoms include morning stiffness, deep aching pain, and knee swelling.

Diagnosis and Treatment

The clinical examination includes history taking, inspection of the knee which is then followed by palpation, testing the range of motion, and muscle strength. The most important part of the clinical examination is the history taking, where the knee pain specialist gets to know about the patient’s innate health, since when the knee pain has started, and about any traumatic event if any. There are some special clinical tests like McMurray’s test, Apley’s test, and Lachman’s test, which help in detecting specific ligament, menisci, and cartilage injuries. These tests provide a high degree of sensitivity and specificity. But the diagnosis cannot be confirmed in many cases, so it is always corroborated with the help of radiological investigations.

For the diagnosis of knee pain, a comprehensive approach is always needed as the cause can be multifactorial. It is the clinical examination done by the doctor which helps in detecting the problem. The main aim of a clinical examination is to localize the structure within the knee joint that is causing the pain. An accurate diagnosis is necessary in framing a correct treatment plan. The treatment plan can be anything ranging from rest to surgery.

Diagnostic Techniques for Knee Pain

Arthroscopy is a surgical procedure that allows the physician to look at the inside of the knee joint. It is probably the most commonly used technique when it comes to diagnosing knee problems. The procedure involves making small incisions in the joint area and then inserting a pencil-sized instrument that contains a small lens and lighting system to magnify and illuminate the structures inside the knee. This allows the physician to take a close look at the inside of the knee behind the patella (knee cap), where the majority of knee problems occur. High quality images from the arthroscope are displayed on a screen, allowing the physician to see the structures of the knee in great detail. This is extremely useful for detecting ligament and cartilage injuries, and the seriousness of a meniscus tear. The physician can also use the arthroscope to look for signs of arthritis. Once the problem has been diagnosed, it can often be treated with the same procedure, as arthroscopy is an effective tool for many surgical interventions.

Non-Surgical Treatment Options

A number of injectables can also provide relief of knee pain. Corticosteroid injections are very effective for relief of moderate to severe pain and inflammation in a short period of time. However, potential effects on articular cartilage and periarticular tissues make it inappropriate for long-term treatment. Viscosupplementation involves the administration of hyaluronic acid, a component of synovial fluid which lubricates the joint, to supplement the reduced viscosity and elasticity of the knee joint fluid in osteoarthritis.

Medications ranging from simple analgesics to glucosamine and chondroitin sulfate are used for pain relief and to combat the ongoing degeneration of the knee. Simple analgesics such as acetaminophen and NSAIDs are effective for mild to moderate pain due to acute and chronic injury. They are relatively inexpensive and have a low side effect profile. Topical agents such as rubefacients and NSAID gels only provide localized relief. Glucosamine and chondroitin are widely used for mild to moderate symptoms due to osteoarthritis. These are usually taken for an extended period of time and may take several weeks to several months to have an effect. Their cost may be a limiting factor for some patients.

Physical therapy is an important part of treatment since it provides an evaluation of the knee, a personalized treatment plan, and instruction on proper exercise techniques. This will guide an individual to pain relief and functional improvement. Step one of the treatment plan is aimed at reducing the pain and inflammation. This is done through electrical stimulation and ice. Step two is to normalize mobility. This is attained through therapeutic exercise.

Exercises are very good for relief of knee pain. It helps to strengthen the muscles supporting the knee and increases flexibility. Strengthening the quadriceps muscles has been shown to be the most important, since the quadriceps muscle takes the load off the knee. Hamstring exercises are also crucial, since the hamstring muscles counteract the pulling of the shinbone.

One of the most common questions asked is whether our knees can heal without surgery. The good news is that the majority of knee pain can be relieved without resorting to surgery. Treatment may vary depending on the specific cause of the pain. Options may include exercises, physical therapy, medications, acupuncture, injections, and weight control.

Surgical Interventions for Knee Pain

High Tibial Osteotomy (HTO) is essentially knee realignment surgery. It is a procedure which is most valuable for a specific type of patient: the relatively young (age under 60), active person with the onset of osteoarthritis in one side of the knee. In this patient, the damaged cartilage will be limited to one specific area and may not yet be severe. The aim is to offload the damaged area of cartilage in the knee to prevent or delay the onset of severe arthritis. This is crucial with the aim of avoiding knee replacement surgery until age 70 or beyond, since knee replacements are not lifelong and do not perform as well in the younger person. HTO involves cutting the tibia (shin bone) and fixating it with a plate and screws in order to change the alignment of the leg. This will take the load away from the damaged area in the knee to the healthy side of the knee or even to the other knee. This procedure is firstly effective. A study stated patient-reported pain and activity of 69% patients with unloader braces were improved to that of a normal person. Next, it is a way of prolonging the standard of life of the specific type of patient mentioned previously who is not yet ready for knee replacement. Success in this procedure will mean delayed arthritis, symptom improvement, and preservation of the knee joint meaning a possible future micro compared to conversion from HTO to Total Knee Arthroplasty (TKA). Although success rates are high, recovery is slow and it is a procedure with obvious short-term loss due to the rehabilitation period.

In osteoarthritis, the ends of the bones become damaged from the wearing and tearing of the cartilage. This is characterized by the formation of bony spurs and cysts. Arthroscopy is a surgical procedure which allows the surgeon to look at the inside of the joint by inserting a small camera through small incisions in the skin. The camera then relays pictures to a monitor which will allow the surgeon to see the condition of the cartilage, ligaments, and the damage in the joint. During an arthroscopy, the surgeon will make these findings and then perform tasks such as washing out the joint with saline or removing loose bodies which cause pain and discomfort in the knee. Although the long-term benefits of arthroscopy are probably not as significant as other forms of osteoarthritis surgery, it will result in improvement in pain and mobility for many patients and is a relatively low-risk procedure.

Preventing and Managing Knee Pain

People who have knee pain should be seeking the best possible treatment to relieve the pain and prevent further damage to the joint. This may often involve professional advice for the alleviation and rehabilitation of the pain. The effectiveness of treatment may be a key factor in the prevention of knee pain and gaining a higher quality of life with a stronger and healthier joint. In cases where people are at occupational risk of knee pain, treatment may need to be timed specifically to allow periods of joint relief during application to the work activity. Measures may have to be taken to temporarily change work activity to a type that places less stress on the knee joint.

Exercise is a vital way of helping to prevent knee pain and giving the joints greater support. However, it must be executed carefully to avoid worsening pain or causing damage to the knee joint. Exercise to strengthen the quadriceps muscles has been proven in a recent study to significantly reduce the risk of developing knee osteoarthritis. This can influence the quality and effectiveness of the exercise in preventing knee pain.

Reducing the risk of injury is a way to prevent knee pain. In order to do this, one must understand the mechanics behind the pain and how knee joints function. Once this is understood, people can be cautious about what activities to carry out and what to avoid in order to prevent placing unnecessary stress on knee joints. Strategies may have to be employed to avoid extending or torsional stress to the knee. This could be something as simple as changing a certain type of footwear or taking extra care while carrying out a specific task.

For people who have knee pain, the reality is that they need to make modifications in their lifestyles to accommodate the pain and forestall further joint harm. Preserving an ideal weight is an important aspect in preventing knee pain. Being overweight increases the stress on the knee joints. This can be done by eating healthily and keeping to a regular exercise routine. This will not only prevent further knee pain but will also have additional benefits to general health and well-being.

Lifestyle Modifications for Knee Pain Prevention

Research has shown that nutrients are important for joint health. For overweight people, losing weight may help to reduce pain and limit the structural progression of knee OA. For example, a recent study showed that a 16-week high protein, low-fat diet combined with exercise helped to improve body composition and physical function in knee OA patients. The added protein helped to build muscle, which in turn helps to protect joints and improve physical function in people with knee OA. High antioxidant intake is also associated with a lower incidence of knee OA. Step one to improving dietary habits is to replace unhealthy snacks with healthier ones. There is a strong body of evidence suggesting that eating patterns and an overall healthy diet may be causally related to decreased occurrence of symptomatic knee OA. An analysis showed that greater adherence to a healthier dietary pattern was associated with a significantly decreased risk of developing symptomatic knee OA. Eating specific foods may also have benefits for preventing knee OA. For example, a study showed that those who consumed a moderate amount of vitamin D had a significantly reduced rate of onset of knee OA as compared to those with lower vitamin D intake. Vitamin D may also help prevent progression of knee OA by reducing the breakdown of cartilage. This is only a recent example of a dietary component that has been shown to alter the risk of knee OA, and more research is needed to understand what nutrients are most important.

Excessive body weight is a significant risk factor for knee OA, as the knee joints bear the brunt of the body’s weight. A person who is 10 pounds overweight has 60 pounds of extra weight on the knees with each step. Weight loss can decrease the chance of developing symptomatic knee OA and slow the disease’s progression. Losing weight has been shown to decrease pain and disability in the knee.

Exercise and Physical Therapy for Knee Pain Management

It helps to avoid repetitive high-impact activities (running, jumping), but loose guidelines make interpreting “repetitive” a guessing game. It is vital to find aerobic exercises like cycling, walking in water, and tai chi to avoid provoking symptoms because they have numerous health benefits. Harmful exercises should be substituted for beneficial ones. Not adding new exercises could be added to this list with the correct dosage. The general belief is that quadriceps weakness and lack of muscular support to the patella are major contributors to patellofemoral knee pain. This is based on a lot of research looking into the vastus medialis oblique (VMO). Although no definitive conclusions have been drawn on the best form of exercise to rehabilitate PFPS, it is clear that strengthening the quadriceps is an important factor to consider. Isometric (static hold) exercises have been found to load the patellofemoral joint to a lesser degree than isotonic exercises and may be beneficial in the early stages of rehabilitation. Open chain kinetic exercises were once thought to be detrimental to the patellofemoral joint; however, recent systematic reviews have failed to find a definitive link between open chain exercises and patellofemoral symptoms. A 2009 article by Witvrouw et al. made the case for including open chain exercises in VMO rehabilitation. The American College of Sports Medicine recommends open chain kinetic exercises, leg presses, and knee extension machines for strengthening the quadriceps as they efficiently load the muscles compared to closed chain exercises. Specificity of the magnitude of load to the quadriceps and VMO is the key for both open chain and closed chain exercises. This can be achieved in the clinic with strength testing and exercise prescription based on the patient’s symptoms.

Tips for Maintaining Knee Health

Finally, control of specific training and/or risky activity was shown to prevent knee pain among student athletes. This can be achieved through physical therapy and modification of specific activity, i.e. knee pads for volleyball players.

Strength training was also highlighted as an important factor in preventing knee pain. Hamstring and quadriceps muscle strength imbalances have been associated with knee osteoarthritis and knee pain. Strength training helps to correct muscle imbalances, and studies have shown that it can alleviate knee pain associated with osteoarthritis and increased physical function.

Finally, the scientists were asked to provide their three best tips for maintaining knee health. They concluded that maintaining a normal body weight, regular strength training, and control of specific training/risk activity will aid in preventing knee pain by reducing stress on the knees. First, maintaining a normal body weight is important as being overweight increases the chance of developing osteoarthritis in the knees by 50%. It was suggested that obese people can specifically decrease the chance of developing knee osteoarthritis by losing a modest amount of weight.

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