Non-Surgical Treatment Options for Knee Joint Pain in Singapore

If the knee joint pain occurs and it has been established that the cause is wear and tear of the cartilage surfaces, then a simple arthroscopy to wash out the knee joint with removal of any loose particles will help. However, the success rate is much lower for patients with established osteoarthritis than for those with mechanical symptoms in the knee from a cartilage tear. This involves loss of blood supply to a segment of bone in the knee and can cause sudden onset of pain but in mild cases it is often symptom free and picked up incidentally on an x-ray of the knee. The most common form of osteoarthritis is due to wear and tear of the cartilage surfaces of the knee. The cartilage becomes frayed and rough and in severe cases can wear down to the bone. This causes inflammation of the joint with production of excess synovial fluid and results in swelling and pain in the knee, particularly after periods of activity or weight bearing. This discomfort is usually relieved by rest but the repetitiveness can lead to development of a Baker’s cyst. This is a collection of synovial fluid at the back of the knee. It forms a bulge and can cause discomfort or restriction to movement of the knee joint. In severe cases of osteoarthritis with advanced degeneration of the knee joint there can be malalignment of the joint due to bone spur formation, cysts and displacement of the joint surface. This can cause further damage to the remaining healthy cartilage and slow progression on the natural healing process of the joint. This cycle will lead to increased pain in the knee and this is often the tipping point where non-surgical management for knee joint pain is no longer effective.

Understanding Knee Joint Pain

Knee is a complex and the biggest joint which permits the leg to bend and straighten, while carrying the body’s weight. The knee joint is made up of the lower end of the thighbone (femur), which rotates on the upper end of the shinbone (tibia), and the kneecap replacement (patella), which slides in a groove on the end of the femur. The joint is formed by the ends of the bones and the ligaments which connect the bones. The ligaments are like strong ropes which help to hold the joint together. Between the two ends of the bones, there are pads called menisci. These are like a smooth wedge, which absorbs the weight-bearing force, and a joint surface which is lined with a smooth articular surface. Normally, all of these components are lined up and the weight is distributed straight down through the knee to the lower leg. It is the alignment of these parts and how the line of force is transmitted which allows movement and stability. Any condition which distorts the weight-bearing alignment of the leg may be a risk for the development of knee arthritis. There are many types of arthritis which can affect the knee joint. The most common type of arthritis to affect the knee is osteoarthritis. Up to two-thirds of the population aged 65 and older have radiographic evidence of osteoarthritis in the knee. In conjunction with the increasing age of the population and the increasing prevalence of obesity, the amount of osteoarthritis in the knee is rising. Other forms of arthritis which can affect the knee are inflammatory in nature, and these include rheumatoid arthritis and gout. Another cause of damage to the knee joint which can eventually lead to the development of knee arthritis is a tear of the meniscus. Meniscal tears occur as a result of twisting the knee and can damage the meniscus and cause knee joint pain and stiffness.

Importance of Non-Surgical Treatment

Prevention: Certain non-surgical treatments can prevent a worsening of condition. Weight loss and exercise can prevent the onset or progression of osteoarthritis. A surgically reparable cartilage lesion has the potential to progress to debilitating arthritis if it goes untreated. A low impact exercise program and use of a brace can prevent symptoms related to a degenerative meniscus. A medical injection can resolve an inflamed synovium and prevent the need for a more complicated procedure.

Outcome: The overall goal is to improve function and pain. High performance or competitive athletes will desire a solution that will allow them to return to their desired activity level.

There is a common misconception that patients let their knee conditions go too far before seeking non-surgical treatment options. However, those patients with mild to moderate conditions can benefit from a wide variety of conservative treatment techniques. Often, patients will partake in a non-surgical treatment for knee pain as the first defense against an exacerbation of symptoms. It is common that a wide definition of non-surgical intervention will include anything from activity modification, pharmaceuticals, physical/occupational therapy, an injection of a medication into the joint, using a cane, a brace, or alternative medical care. Patients usually do not consider surgery until the pain and loss of function becomes severe. Consider the following when undergoing non-surgical treatment for non surgical treatment for knee joint pain:

Non-Surgical Treatment Methods

A lack of consistency on what these descriptions mean can result in wide variation of treatment from one therapist to the next. This has led to the recent publication of a treatment algorithm in an attempt to reduce subjective treatment choices and improve consistency of treatment to an optimal standard. This consisted of a workshop to teach the protocol to the therapists, provision of a pocket-sized algorithm guide, and course of patient information booklets. The preliminary results from this protocol show a positive impact in consistency of treatment and although promising, further research is needed to assess its impact on patient outcome. Any form of manual therapy is discouraged as evidence shows no positive long-term benefit and a potential to cause increased joint irritation and progression of knee OA.

Physical therapy is a very effective treatment for patients with knee problems. This should be carried out by a physiotherapist with a specific interest in knee problems. There are many choices of treatment; it often begins with advice on activity modification and exercises to strengthen the quadriceps and hamstrings. To be effective, all exercises should be performed to the point of mild fatigue without the onset of pain during or after the session and should be performed in a pain-free part of the range of motion. Any exercise that causes a significant increase in pain or swelling in the joint should be discontinued as this is a sign of irritation to the joint. Exercises to work on control of the hip and trunk, balance, agility, and proprioception are also important. These are often performed with a mirror to provide feedback on the quality of movement.

Physical Therapy

Therapeutic Exercise These are exercises designed to restore strength, endurance, and function of the knee to support and promote healing. These range from isometric (muscle setting) exercises performed early in the pain management process, with the use of light resistance bands, to isotonic exercises against some form of resistance to improve strength and endurance of a particular muscle group, to functional/weight bearing exercises aimed at promoting coordination and endurance to allow a return to activities of daily living. The type of therapeutic exercise used depends considerably on the specific problem being addressed with an overall goal of returning the patient to a pain-free state and being able to participate in desired recreational and vocational activities.

Introduction Physical therapy is a significant movement-based treatment aimed at promoting tissue healing and restoring function. It’s a treatment method that is widely used around the world and in Singapore for knee discomfort and pain. It has many facets, some of which are used almost exclusively on knee pain, while others involve treatments which affect the knee secondarily to treatment of other lower extremity related issues.

Medications and Injections

Physical therapy can be helpful for those suffering from osteoarthritis and it can be taught to patients as an independent form of treatment or it can be combined with other forms of treatment after knee joint assessment. Strengthening the muscles around the knee joint can reduce the stress on the joint itself. Then, it will absorb the shock exerted by the lower extremities during normal daily activities. Range-of-motion exercises will improve function and prevent disability of the knee. For bleeding, abnormal blood clotting or an underlying disease of the blood vessels, R.I.C.E. (rest, ice, compression, and elevation) can be helpful, as well as periodic removal of excess fluid from the knee joint. A physician might recommend using a cane to help reduce the stress on the joint. Orthoses have been demonstrated to reduce pain and disability of the knee OA patient. Lateral wedge and flat foot insole, patellar taping, knee sleeve and valgus brace are available to help treat the uni-compartmental osteoarthritis patient. In addition, weight loss is a great way to reduce symptoms and it has been speculated that for every 1 kg of weight lost, there is a 4-fold reduction in load exerted on the knee for each step taken. High intensity exercise and weight reduction can be achieved through participation in sport and exercise program, recreational activities and lifestyle fitness and nutrition coaching. An exercise regimen should consist of aerobic, resistance, flexibility and body awareness components. Knee joint injury patients should understand that the knee joint is sufficient when doing a certain exercise or activity and to gradually increase exercise duration and intensity.

Non-surgical treatment methods

Regenerative Medicine

Commonly, regenerative medicine treatments are the injection of platelet rich plasma, stem cell transplantation and more recently a culture-expanded mesenchymal stem cell injection. A platelet rich plasma injection is a simple and minimally invasive procedure that takes a small volume of blood from the patient and then using a centrifuge reinserts a concentrated dose of platelets and growth factors.

Regenerative medicine is the practice of replacing, engineering or regenerating human cells, tissues or organs to restore or establish normal function. It has been hailed as a game changer in the treatment of many orthopaedic injuries and to date the evidence supports its use in the treatment of mild to moderate degenerative arthritis. Regenerative medicine is an innovative medical practice that promotes the repair of injured tissues by using the body’s own natural healing processes. This treatment works by increasing the body’s healing potential, repairing injured tissues with new cellular growth and minimal scar tissue formation. The theory and evidence behind regenerative medicine is to boost the natural repair cycle and thereby restore normal tissue architecture and cell function.

Lifestyle Changes for Managing Knee Joint Pain

– Range of motion and stretching exercises (e.g. yoga) to maintain flexibility of the joint and surrounding muscles. – Strengthening exercises to increase the strength of muscles supporting the knee joint – particularly quadriceps (thigh) muscles as strong quadriceps muscles absorb stress on the knee and keep the joint aligned. – Low-impact aerobic activities to help reduce pain and disability but still provide cardiovascular benefit. Water-based exercises or swimming are good examples as the buoyancy of water reduces impact on the knees. – Avoidance of aggravating activities e.g. prolonged standing, heavy lifting, or high-impact activities that involve sudden stopping and starting, jumping, or change in direction such as basketball or tennis. These activities can switch to a purposeful walking program to increase aerobic fitness while reducing impact on the knees.

Exercise is an important part of life and daily exercise is beneficial for general health, conditioning the body, and preventing or minimizing musculoskeletal pain and disability. The mode, intensity, duration, and frequency of the exercise can be adapted according to the individual’s needs and symptoms. There are 4 main types of exercise that can be performed to manage knee joint pain:

Exercise and Weight Management

Muscle atrophy is a natural result of pain and injury to the lower extremities. When a limb is in pain or has been injured, there are altered neurological signals in the muscles which makes them slowly decrease in size and strength. If the pain or injury is persistent, muscle atrophy can become severe. It is particularly important that people with knee pain keep their quadriceps muscles strong because it is a lack of quadriceps strength that leads to knee osteoarthritis.

The best form of exercise for knee pain is low-impact aerobics. This can be done with stationary bikes and elliptical machines, or by walking, which is the most accessible form of exercise. Patients should level with themselves and not overdo it. It is a common belief that exercise is only beneficial if it is vigorous. This is a misconception because even a small amount of exercise has health benefits. In older adults, some of the health benefits of aerobic exercise are lost within a few weeks of stopping. Swimming is an excellent form of exercise because the body is supported by water, which reduces stress on the joints.

Exercise has been proven to be among the most effective approaches to addressing knee pain. Exercise increases the strength and function of the muscles that stabilize and support the knee joint. When the thigh muscles are strong, they can absorb a lot of the force that comes through the knee. This reduces the stress on the joint itself. Strong hamstring muscles protect the knees from injury, particularly tearing an ACL.

Assistive Devices and Orthotics

Knee braces are worn for a variety of problems and are designed to provide support or correction. Prophylactic knee braces are designed to prevent or reduce the severity of injuries to the medial collateral ligament. Functional braces are intended for use after MCL injury to provide support while promoting healing and rehabilitation. Unloader or offloader braces are designed to reduce the weight going through the affected compartment of the knee. There are many that feel that an “unloader” brace is a cheaper, safer and more reversible alternative to osteotomy. The effectiveness of braces can be quite subjective and what works for one patient does not necessarily mean it will work for another. Step one buys it mange it is not necessary that it’s going to work for me but it’s worth a try.

Assistive devices and orthotic interventions are commonly prescribed to patients with knee OA. Their main purpose is to reduce pain and improve or maintain functional status. Sometimes a cane may be the simple solution to offload a painful and arthritic knee. There have been significant technological advances in the design of assistive devices with the most notable being the “offloader” brace for unicompartmental OA. These are custom fit braces that are designed to shift the load away from the affected compartment of the knee. They work by using 3 points of pressure to change the line of action of the ground reactive force vector. This type of brace is often favored by patients who are too young for joint replacement or who are not suitable for realignment osteotomy.

Alternative Therapies

The use of magnets is a cheap alternative therapy and it is believed to have an intrinsic healing effect. Magnets can be used in the form of magnetic wraps, straps, or insoles. A localized, high-strength static magnetic field has the ability to reduce swelling and pain by affecting cellular function. It can also improve blood circulation around the affected area. A study conducted by Winfield et al concluded that magnetic treatment was extremely effective in water retention and pain relief in 76% of patients. Static magnets are considered safe to use with no side effects, however, there has been no clear scientific evidence that can prove the efficacy of magnetic therapy.

Another alternative therapy is consuming shark cartilage. Shark cartilage has been known to have an anti-inflammatory effect and help to rebuild damaged cartilage. Several patients consuming shark cartilage have reported feeling that it helps to reduce their joint swelling and pain. However, there are no randomized controlled trials or large-scale studies that can prove the efficacy of shark cartilage in relieving osteoarthritis symptoms. Furthermore, there are issues of safety and ethics in obtaining shark cartilage as it involves harvesting the cartilage from sharks, which are endangered species due to overfishing.

Various types of alternative therapies that have been used in Singapore can be effective for knee pain. Acupuncture is a popular alternative therapy that originated from China and is commonly used by Chinese patients in Singapore. It is believed that acupuncture can help to relieve pain and inflammation in the affected joint. The exact mechanism of acupuncture is still not fully known, but some studies have shown that it can stimulate the release of endorphins and have an anti-inflammatory effect.

Seeking Professional Help in Singapore

Many patients are unsure which specialist services to seek due to similar symptoms and conflicting information regarding the nature of their condition. It would be beneficial if there were some form of health professional to help patients better understand their disease and make the right decision regarding choice of specialist and course of treatment. Currently, there is a lack of disease specific health professionals in the public sector. A patient may resort to seeking the opinion of different specialists. This is both time consuming and costly in terms of specialist fees and tests. An example of an effective allied health service is a Clinical Nurse Specialist in the UK which aims to advance patient care by providing information through patient and family education, effectively helping patients to cope with their condition and make informed choices about their treatment and care. With a better understanding about their disease, patients are more likely to opt for non-surgical treatment since many orthopaedic surgeries were found to be for end-stage osteoarthritis and had little benefit.

Chronic knee joint pain in the elderly due to degenerative conditions like osteoarthritis is a common issue confronting the Singapore healthcare system. The majority of treatment is non-surgical and it begins with the patient visiting a doctor for consultation. He should see a family physician for an overview of the problem and further referral to a specialist if necessary. Typically in Singapore, a patient is referred to an orthopaedic surgeon. While this is practical in severe cases, a study by Singapore General Hospital revealed that up to 80% of the cases could be managed by a rheumatologist. Other specialists to consider are sports physician, rehabilitation physician and even a pain management specialist. This would depend on the nature of the condition and the needs and expectation of the patient.

Choosing the Right Medical Specialist

For example, in Jean’s situation, understanding that there are several different kinds of health providers in existence can be confusing for the patient who is looking for treatment. In most situations, patients often do not understand what the difference is between the types of providers or what specific providers are trained to do. According to an article by the American College of Rheumatology, there has been a rapid increase in the number and proportion of non-physician providers caring for elderly patients with arthritic conditions. This can be seen as beneficial for some patients because non-physician providers such as physiotherapists or occupational nurses may spend more time with the patient during the encounter and they will likely pay more attention to functional independence and less attention to medical management. By contrast, some patients might misunderstand the qualifications and Constitutional privileges of the non-physician provider with negative effects. This might lead to a situation where a patient with an advanced arthritic condition sees a therapist and is encouraged to try several types of minimally effective exercise therapy prior to seeking evaluation by a physician.

Jean walked into the examination room with a puzzled look on her face, prompting the very first thing she stated, “I thought I was going to be seeing the bone doctor.” Like many people, Jean assumed that a medical professional who specializes in bone and joint disorders was the exact same as an orthopaedic surgeon. She had been referred to the specialist because her family physician had diagnosed her with osteoarthritis a few weeks ago. Jean sits down in the chair and is trying to remember all of the questions that she had planned to ask during the time leading up to the consultation. Now she is drawing a blank and her doctor is explaining that he will be giving her a corticosteroid injection to try and alleviate the discomfort that has been associated with her osteoarthritis and help her to regain function in her knee. The physician explains that the procedure is extremely safe and typically effective, however Jean is having reservations based on a previous experience she had with a different specialist.

Evaluating Treatment Options

Once an accurate diagnosis has been made, the treatment options for knee pain fall into two broad categories: surgical and non-surgical. This section focuses on the non-surgical options. In general, all treatment is tailored to the nature and severity of the knee pain and will often require a period of trial and error. This is because the same condition can cause varying degrees of pain and functional impairment in different people. A successful regimen may involve a combination of different treatment types. Non-surgical management is the first consideration in alleviating knee pain and improving mobility. This is usually the initial recommendation for patients with knee osteoarthritis, unless there are particular findings that indicate a high likelihood of success with a surgical approach. The principal advantage of non-surgical treatment is that it carries less risk, cost, and requires less post-treatment rehabilitation time.

Cost and Accessibility

Patients with significant knee pain should seek a referral from their general practitioner to see a specialist doctor. Orthopaedic surgeons are doctors who specialize in surgical and non-surgical treatment of the musculoskeletal system (bones, joints, muscles, and ligaments). There are many orthopaedic surgeons in Singapore who are able to offer surgical and non-surgical treatment options for patients with knee joint pain. Some orthopaedic surgeons only offer surgical treatment, and a patient may want to seek out a surgeon who is interested in exploring and making use of the many available non-surgical treatment options. A good way to find a specialist doctor or orthopaedic surgeon in Singapore is to approach any private hospital, sports injury clinic, or government restructured hospital. If a patient has a certain type of non-surgical treatment in mind, they should inquire with the doctor as to whether this treatment is available and suitable for their knee condition. As mentioned previously, the use of hyaluronic acid joint injections is quite a popular option in Singapore as compared to other non-surgical treatments. This is due to the fact that hyaluronic acid joint injections are minimally invasive and simple to administer. If the doctor recommends this treatment, patients will have little difficulty in finding a doctor who is able to carry out this procedure.

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