Physio-pedia has fantastic illustrations and anatomical breakdown of the knee joint. It is a hinge joint made up of a synovial joint capsule coupled by tendons (that connect the knee bones to the leg muscles) and ligaments (that join the knee bones and provide stability to the knee).
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Knee Pain - a topic overview and general discussion
| By: Dr. J | a board certified Internist and Nephrologist practicing in the DC/Metropolitan area with over 30 years of clinical experience
The knee joint’s purpose is to join the bones of the lower leg (the Tibia (shin bone) and fibula) with the Femur (thigh bone). It has the largest articulating surface of any joint in our bodies. This connection enables us to partake in activities such as standing, walking, and running. As a result of the tremendous and variable pressure/force this apparatus takes on - it is particularly susceptible to injury. Let's take a deep dive into some of the common ailments of our knees.
Knee pain can broadly be broken down into 2 encompassing categories - Acute pain (typically less than 8 weeks) and Chronic pain (typically greater than 12 weeks). The knee joint has classically been susceptible to many acute injuries from trauma ranging from bruises to ligament strains to more severe structural damage such as a basketball player tearing an ACL ligament. Chronic pain is likely due to the long term stress/shear force placed on the knee - studies have estimated that chronic pain at the knee
affects approximately 25 percent of adults . Sadly - By 2025, the
prevalence of knee OA is expected to increase by 40% , largely due to an aging population and the obesity epidemic.
Risk Factors for Developing Knee pain include:
- Past trauma/injury - past knee injury increases risk for chronic knee issues/pain as individuals age
- Overweight/Obese - increases pressure on knee joints which can increase the breakdown of cartilage and subsequent arthropathy of the knee
- Overuse - repetitive stress on the knees from jogging or basketball or certain occupations can increase the risks for joint degradation/cartilage erosion
- Muscle weakness/stiffness - A lack of support muscle strength and flexibility can increase the risk of knee injuries. Strong muscles help to stabilize and protect your joints, and muscle flexibility can help you achieve full range of motion.
Symptoms of knee pain include:
General Aches/Pains locally to the damaged region
Muscle weakness
Impaired Mobility
Inability to straighten the knee
Stability issues/falls
Causes of knee pain include:
Degenerative Joint Disease - Osteoarthritis usually due to combination of aging and wear/tear is the most likely etiology of chronic knee pain
Fractures - Bones of the knee/kneecap can break due to trauma especially if osteoporosis (weakening of the bony structure) is present
Meniscus damage - sheer stress can tear the meniscus (a cartilage based structure that acts as a shock absorber between the thighbone and shinbone)
Ligament Strain or tear- tissue injury typically as a result of awkward movement or shear stress
Bursitis of the knee - the bursae can get inflamed and painful (it is a small fluid filled sac that cushions the outside of the knee joint and allows ligaments and tendons to glide smoothly over the joint)
Patellar Tendinitis - this tendon attaches the quadriceps muscle on the front of the thigh to the shinbone and can get inflamed/damaged (particularly in heavy use/stress via running/cycling/skiing)
Immune mediated Arthropathy - such as Rheumatoid Arthritis of the knee (and many other joints of the body can be affected by RA) - a form of arthritis that involves the body's own immune system attacking its own joints. WebMD provided a more detailed overview of RA on the knee
Kneecap damage / dislocation - the patella (bone that covers the front of the knee) can slip out of place
Iliotibial Band Syndrome - tough band of tissue that extends from the lateral aspect of the hip to the lateral aspect of the knee. It can tighten typically from repetitive use (like distance running or cycling) and can apply pressure on the outer portion of the femur
Gout - can have uric acid crystal deposition and subsequent inflammation and tenderness of the knee joint (not as common of a gout joint as the toe)
Septic Arthritis - a typical bacterial infection of the knee joint leading to inflammation/tenderness and even systemic symptoms such as fever/chills
Therapy options for Knee Pain
Acute Knee Pain ( more information from Heathline here ):
1) Associated with high force trauma (motor vehicle crash or fall from height)
-Likely need acute evaluation (such as Emergency Room) with Xray to ensure no fracture and a potential MRI to assess for more intricate structural damage
2) Associated with Low force trauma
- Likely need non emergent but formal evaluation to assess for structural damage and may need imaging to assess structure (such as an MRI)
If no structural issue is noted on examination or imaging - the good news is most acute knee pain issues will improved with a combination of:
Rest
Anti inflammatory medications and/or muscle relaxants
Time (usually in 1-2 weeks from initial presentation/injury to slightly longer if it is a wear/tear injury such as patellar tendinitis or Iliotibial Band Syndrome)
Unfortunately - as WebMd notes here - data has shown that acute structural knee injuries does significantly increase the risk for chronic knee issues as one ages.
Chronic Back Pain Therapy options consist of usually an algorithm based treatment plan to help alleviate/maintain symptoms (a good reference here from the Mayo Clinic ):
1) Nondrug/Non surgical Therapies:
a. Physical therapy/Exercise - strengthen/stabilize muscles around the affected joint/area
b. Weight Loss – Alleviate pressure and shear force on the knee joint
2) Medications - used to control inflammation/pain:
a. NSAIDs – Non Steroidal Anti-inflammatory Drugs – one of the most commonly used medications in the world. Advil / Aspirin / Motrin / Aleve / Naproxen / Ibuprofen / Motrin / Diclofenac are all examples of NSAIDs. The issue is they are to be Cautioned/Avoided in individuals with multiple medical issues such as Chronic Kidney Diseae / Congestive Heart Failure / Gastritis or Stomach ulcers / Resistant hypertension.
b. Acetaminophen – commonly recommended when physicians ask patients to avoid NSAIDs. Ex: Tylenol Arthritis – the problem is multiple past studies (and decades of our clinical patient encounters) have shown minimal (if any) anti-inflammatory effectiveness
c. Opioids – Controlled narcotics pain medication that is classified as an unfortunate epidemic in the USA. These medications bind to opioid receptors in the brain/spinal cord and blunt to pain signals. The issue is they have dangerous side effect profile (can be fatal) and also patients develop tolerance and are in need of larger dosages which can lead to a potential addiction or overdose
3) Surgical Options
a. Joint injection – commonly performed by orthopedic surgeons or rheumatologists – typically are either a corticosteroid injection to suppress inflammation locally or a hyaluronic acid injection to provide some degree of joint cushion. The issue is both are short term solutions that typically lead to recurrent issues
B. Platelet-rich Plasma (PRP) - commonly performed by a sports medicine or orthopedic doctor - PRP contains many growth factors that may potentially reduce inflammation and promote healing (study data is mixed though on the long term effectiveness though).
b. Joint Surgery – commonly performed by an orthopedic surgeon. Such as a total knee arthroplasty . The issue is these are invasive surgeries that carry risk of anesthesia/cardiac events/infections/blood clots and may be difficult especially in the elderly population
Above is a detailed overview of this complex but sadly common issue that is rising across our country and in our world. As a practicing Nephrologist (Kidney Doctor) - I generally never get consulted to manage osteoarthritis but end up playing a large role in the symptom control of my patients.
The most common reason for a patient to see a Nephrologist is for a diagnosis of chronic kidney disease . Our goal is to help slow the progression of this CKD by optimizing risk factors that historically damage kidneys and attempt to avoid progression to a need for renal replacement therapy (dialysis or kidney transplant). Every Nephrologist I know would immediately ask a patient to stop all NSAIDs such as Advil / Motrin / Alleve / Naproxen / Ibuprofen along with several prescription strength NSAIDs such as Diclofenac / Voltaren / Celebrex / Indomethacin / Meloxicam. The only regular recommended alternative is Tylenol (Acetaminophen) Extra Strength or Arthritis at recommended dosages to control aches/pains/inflammation. The issue: Acetaminophen has weak data on arthritis/inflammation control
More often than not our patients come back to us saying they are not achieving adequate management without NSAIDs. Opioids are almost never the right answer for osteoarthritis related pain management (they do not suppress joint inflammation and have a very unfavorable risk profile). Injections/surgeries are invasive and have their drawbacks especially in patients with more advanced chronic kidney disease. We had to research this field to find a safe and effective alternative for our patients!
Several herbs have been used in holistic medicine for generations for inflammation control such as curcumin, capsaicin extracts, ginger, willow bark, cloves, fenugreek, or nigella sativa. There is a multitude of bench data as well as clinical trial data (including several randomized control trials) for several of these herbs/extracts. We began looking into herbal/holistic substances and we parsed basic science/bench as well as clinical research databases. Our ingredients have shown to suppress the inflammatory cascade with the caveat of no known issues with kidney function / Sodium retention or swelling / Blood Pressure elevation / stomach lining erosion that plague chronic NSAID use. In 2014 after some testing and adjustments - we solidified a powder based regimen and would at times suggest patients seeking alternative/additional relief try it. We did not commercially sell it but would just suggest individuals obtain and try the ingredients on their own.
The response was tremendous and more often than not this became their go to relief agent. The only consistent suggestion (and complaint) was the taste of the powders and the need for a tablet to ease delivery/use. We adjusted the extract ratios/concentrations and were able to manufacture (made in the USA at an FDA registered and GMP certified facility) a coated (should be tasteless) tablet also scored to decrease size to help ease use. The feedback and reviews have
been phenomenal (click here to see our Amazon reviews). We sincerely hope Organic Arthritis assists you in staying active and on your path to healthy and meaningful living. Thanks for taking time out to join me on this journey! Thank you for sharing your time with me on this blog! Thank you for sharing your time with me on this blog!
Osteoarthritis is commonly referred to as the “wear and tear” degenerative joint disease. It typically results from the gradual loss of cartilage - the tough connective tissue that is within/between joints. In a way too simple analogy of this complex mechanism - this cartilage serves as essentially a shock absorber preventing direct shear force or “bone on bone” pressure. Once the shock absorber is weakened/gone – trauma will slowly lead to inflammation and erosion of the joint (PAIN!). This leads to a pretty straightforward question - is there a way to repair or at the least slow down the decline of cartilage? Enter Glucosamine - which is an amino sugar and precursor in the synthesis of glycosylated lipids and proteins. It is a natural compound that exists in our cartilage.
Osteoarthritis is one of the most common medical conditions in the world and is commonly referred to as “wear and tear” degenerative joint disease. It typically results from the gradual loss of cartilage within/between joints. This cartilage serves as a type of shock absorber preventing direct shear force and “bone on bone” pressure. Once the shock-absorber is gone it will slowly lead to inflammation and erosion of the joint. US Centers for Disease Control data estimate approx 60 million people with doctor diagnosed arthritis – and remember many people live with joint aches/pain without seeing a physician or getting a formal diagnosis of OA. Sadly the symptoms of OA simply do not stop at the joint. The Arthritis Foundation notes that individuals with OA are almost three times more likely to develop cardiovascular disease (CVD) or heart failure than those without OA. Also, people with osteoarthritis experience as much as 30 percent more falls and have a 20 percent greater risk of fracture than those without OA. These links are especially strong when arthritis is in certain weight bearing/balance joints, such as the knee/back/hip. It makes sense – pain/weakness especially in our stabilizing joints such as knees/hips/spine will limit mobility and lead to risk factors such as weight gain, cardiovascular disease, diabetes coupled with stability issues. These patients would have difficulty following American Heart Association recommendation s that recommend increased physical activity and note that becoming more active can help lower blood pressure and also boost levels of good cholesterol. Without regular physical activity, the body slowly loses its strength, stamina and ability to function well - People who are physically active live about 7 years longer than those who are not active and are obese (American Heart Association). Studies have shown that adults who are inactive/minimally active more than 4 hours a day had a 46% increased risk of death from any cause and an 80% increased risk of death from cardiovascular disease! So now let us focus on some of the clinical presentations of Osteoarthritis (OA). In general there is a marked variability of disease expression. Although most patients present with joint pain and functional limitations, the age of disease onset, sequence of joint involvement, and disease progression vary from person to person. OA ranges from an asymptomatic, incidental finding on clinical or radiologic examination to a progressive disabling disorder eventually culminating in "joint failure" with impaired mobility and quality of life. The primary symptoms of osteoarthritis (OA) are joint pain, stiffness, and motor restriction. Symptoms usually present in just one or a few joints in a middle-aged or older person. Other manifestations in patients with OA include sequelae such as muscle weakness, poor balance, and associated conditions such as fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues).
Osteoarthritis is oftentimes characterized in simple terms - typically referred to as a “wear and tear” injury to a specific joint. This usually involves the weight bearing joints of the body such as the lower back (lumbar spine), the hips, or the knees but can also include common repetitive use joints such as the fingers/toes and also the ankle (especially if historical trauma/injury is noted). In actuality - osteoarthritis is a complex system with many mediators that can affect degradation of joints/cartilage. There are multiple mechanisms that can help trigger erosive joint disease - including several metabolic triggers. In this excellent review by Wang/Hunter et a l from Osteoarthritis and Cartilage - they have an interesting info graphic highlighting potential metabolic contributors to OA (shared below).
Falls are a major issue especially in our elderly population and falls are the leading cause of injury, both fatal and nonfatal, among older adults in the United States . I can not even count the number of lives that were significantly (and often times permanently) changed after a fall through my decades of practice as a Nephrologist and Internist.
Cultures around the world, originally in eastern philosophy, have utilized mind body movement exercises for generations for various potential mental and physical benefits. These practices have increased in popularity and scope and are now truly global disciplines such as yoga and tai chi . Yoga likely was founded in Indi a and entails discipline in physical, mental, and spiritual realms with originally strong followings in the hindu and buddhist doctrines. It has morphed from being tied to a single country and also bypassed religious connotations. The term "yoga" in the Western world often denotes a modern form of hatha yoga and posture-based physical fitness, stress-relief, and relaxation techniques sometimes accompanied with breathing exercises The focus of yoga in this modern sense is to blend posture based positions/poses to help facilitate exercise for the body and potentially mind. There are many different disciplines/variations of Yoga with significant fluctuations in their physical demands. Many researchers/physicians attempt to quantify the strenuousness of exercises by their energy cost of exercise commonly measured in metabolic equivalent of task (MET). Less than 3 METs counts as light exercise; 3 to 6 METs is moderate; 6 or over is vigorous. American College of Sports Medicine and American Heart Association guidelines count periods of at least 10 minutes of moderate MET level activity towards their recommended daily amounts of exercise. For healthy adults aged 18 to 65, the guidelines recommend moderate exercise for 30 minutes five days a week, or vigorous aerobic exercis e for 20 minutes three days a week. Treated as a form of exercise, a complete yoga session with asanas (body posture) and pranayama (focusing on breath) discipline provides 3.3 ± 1.6 METs which would be classified as an average/moderate workout in strenuousness. There have been several hundred published articles/scientific trials on Yoga and its potential health benefits. Let us focus on some of the data for arthropathy. In one randomized control trial by Deepeshwar et al - Sixty-six individual diagnosed with with knee osteoarthritis (ages between 30 and 75 yo) were randomized into two groups. One group would then participate in yoga for 1 week at a yoga center ( n = 31) and then a control ( n = 35) group who did not participate in any yoga activities. Multiple functional tests were performed on day 1 and then at day 7 - including the Falls Efficacy Scale (FES), Handgrip Strength test (left hand LHGS and right hand RHGS), Timed Up and Go Test (TUG), Sit-to-Stand (STS), and right & left extension and flexion. Results indicated a significant reduction in TUG ( p < 0.001), Right ( p < 0.001), and Left Flexion ( p < 0.001) whereas significant improvements in LHGS ( p < 0.01), and right extension ( p < 0.05) & left extension ( p < 0.001) from baseline was found in the yoga group. This would suggest improved muscular strength, flexibility, and functional mobility in the yoga group. This was a small study that also was completed over a short time frame (1 week) but did show marked functional improvements. Let us look at more data via a large review by Haaz et a l . Researchers combed through peer-reviewed clinical trials (published from 1980-2010) that used yoga as an intervention for arthritis patients and reported quantitative findings. Eleven studies were identified, including four randomized control trials and four non randomized trials. The trials reviewed data is below in the table.
Let us review an interesting study from the Harvard medical system published in the American Journal of Clinical Nutritio n and also Osteoarthritis and Cartilage Journal by Xu et all dealing with the potential impacts of dietary intake patterns and progression of Knee osteoarthritis. There is an age old saying - "You are what you eat" and there has been past data on certain foods/nutrients linked with outcome effects on knee arthritis such as (click the links below for reference articles): Soft drink consumption (potential increased risk of OA progression) Milk consumption (potential decreased risk of OA progression particularly in women) Dietary fat intake (potential increased risk of OA progression) Strawberrie s (potential decreased risk of OA progression particularly in obese adults) Fiber intake (potential decreased risk of OA progression) We also know of many herbs that have varying arthritis control data (some very convincing) and our own Organic Arthritis Herbal Supplement is composed of strong data driven herbs for arthropathy control. There have been past study links between a general Mediterranean diet having a relative lower risk of and improved overall symptom control of knee OA. This study focuses more on overall diet classes and effects on osteoarthritis. This study compares two diet classes based on the Scree test via individual diet questionnaires: Western Diet - composed of high intakes of red and/or processed meats, refined grains, and french fries Prudent Diet - composed of high intakes of vegetables, fruit, fish, whole grains, and legumes
Arthritis is one of the most common medical conditions diagnosed in the United States and world-wide. CDC US data notes there are approximately 60 million individuals battling arthropathy with that estimate rapidly growing to an estimated 78 million (26%) US adults aged 18 years or older projected to have doctor-diagnosed arthritis by 2040 .
Many of us have heard of the medical term INSOMNIA . It refers to a medical condition in which individuals have difficulty falling, staying, or getting back to sleep. There can be short term sleep issues lasting nights or weeks, termed acute insomnia , or long term sleep disturbances ranging months to years, termed chronic insomnia . This can lead to a multitude of general health ramifications. The first question - how much sleep is recommended daily? According to United States Centers for Disease control recommendations - adults should generally have 7 or more hours of sleep nightly to help ensure optimal functional status. This CDC table below helps show National Sleep Foundation and American Academy of Sleep Medicine recommendations:
Knee Arthritis - a review on exercise, weight loss, and physical therapy!
There is a strong chance all of us are aware of or have used non-steroidal anti-inflammatory drugs (commonly referred to as NSAIDs) in our lifetimes. There also is a good chance many have been told by their medical providers to avoid using NSAIDs especially long term given the risk factors for particular those with chronic kidney disease, congestive heart failure, resistant hypertension, gastritis/stomach ulcers, or even those with electrolyte concerns such as hyperkalemia (high potassium) or hyponatremia (low sodium). Despite these risks – NSAIDs are simply the most recommended/prescribed anti-inflammatory medications in the world today. This class of medications includes such commonplace names as (click underlined links below for more info): 1) Advil 2) Aleve 3) Ibuprofen 4) Motrin 5) Naprosyn/Naproxen 6) Diclofenac/Voltaren 7) Celebrex/Celecoxib 8) Mobic (Meloxicam) 9) Indomethacin/Indocin Though often times effective for inflammatory control - there are several noted risks to NSAIDs particularly in those with chronic kidney disease. NSAIDs provide their analgesic, anti-inflammatory, and antipyretic actions through inhibition of cyclooxygenase (COX) enzymes – which convert arichidonic acid (released from cell membranes) to prostaglandins and thromboxanes. This graphic in the American Journal of Kidney Disease highlights this COX cascade pathway affects: