Causes of knee pain | Understanding symptoms | Diagnostics | Nonsurgical treatments | Surgical options | Joint Replacement | Knee prevention
You are an active weekend warrior in your 40s and your ideal fun weekend would include two hours of tennis, some running or walking 18 holes. That is, if your arthritic knees could handle it, and they can’t anymore because your knee joint feels like bone scraping on bone. Even walking some days can be excruciating.
Worse, your orthopedic surgeon has told you that at age 40, the lifespan of an artificial knee joint, or hip joint, is about 15 years. That puts you at 55 looking at a second knee replacement surgery which gets increasingly complex, and then a third complex surgery at age 70 — all at a time when your health issues mount. The math, your doctor tells you, simply doesn’t work.
So you are stuck with knees that make climbing stairs or walking across a large parking lot appear as daunting. excruciating journey. Small comfort in that you see others your age hobbling around, as osteoarthritis affects more than 32.5 million people in the United States. According to federal data, 754,000 knee replacements and
Your physician may prescribe oral medications for the relief of arthritis pain or joint pain. This can include pills with Aspirin, ibuprofen and naproxen which can relieve pain and reduce inflammation.
If oral medications fail to provide relief, your orthopedic surgeon may recommend an injection of medication into the joint. An injections can offer quick, effective pain relief. However, joint injections with either cortisone, steroids or other medication have limits because over time excessive use can damage the joint.
In some cases, knee pain can be alleviated by something as simple as using a foot orthotic or knee brace. Foot orthotics are orthopedic devices like insoles or supports that are usually custom fit to control the foot and correct imbalances. An orthotic foot support can raise the arch of the foot and realign the bones of the foot to prevent excess motion when you bear weight. Foot problems can sometimes cause ankle, knee, hip, and back problems.
If you are an avid runner, and you are suffering from knee problems, you may want to explore an orthotic foot device. The device could position your foot in such a way that knee pain could be alleviated.
Many times, improper foot mechanics leads to improper running or other physical motion, and this can damage the knee. If you are suffering from arthritis, or you are overweight, the foot orthotic could help by repositioning your foot and counteracting stress on your knee to allow greater comfort and mobility for greater lengths of time. Orthotics come in rigid, semi-rigid, and soft materials. The rigid materials are generally prescribed when entire control and support is needed. The semi-rigid materials offer support, but they also allow for shock absorption.
Knee braces can be used to help an existing knee injury, or to protect the knee from future injury. Before these devices are used, you should consult with a physician. If worn improperly, the brace could do damage, and wearing it for a long period of time would not allow the muscles around your knee to grow stronger.
A study from the Surgical Clinic of the Ullevaal Hospital at the University of Oslo in Norway found that patients in their study using a knee brace after anterior cruciate ligament (ACL) reconstruction had increased thigh atrophy after wearing the brace for three months.
Said another way, using a brace is like using a crutch. While it can help you become active after an injury, depending upon it excessively doesn’t encourage the supporting muscles to strengthen. And in a sense, you become dependent upon that crutch, so when it isn’t there, you can have problems.
With that said, a subliminal function of a knee brace is that it can act like a string around your finger—to remind you to be careful during activity, and not be overly aggressive with the knee joint.
Hyaluronic acid injection is used to treat osteoarthritis. Hyaluronic acid is similar to the natural synovial fluid found in the joints. It works by acting like a lubricant and shock absorber in the joints and helps the joints to work properly.
During the procedure, the orthopedic specialist injects hyaluronic acid directly into your knee joint. The injection is repeated for up to 3 to 5 weeks. While the FDA has approved this treatment only for osteoarthritis of the knee, some use it for other arthritic joints as well as they report that it acts like lubricant in the joint.
Hyaluronic acid injections do not seem to work for all people. Those who are older or have advanced arthritis, may be less likely to find relief from these injections. Generally speaking, Hyaluronic Acid is often a last resort before more invasive knee surgery.
There can be some swelling in the knee area as a side effect of the injection. One study in 2016 in the journal Systematic Reviews found the possibility of serious side effects outweighed the benefits.
Another non-surgical treatment option that is being explored is the use of tiny pellets that might treat arthritic knee pain, delaying the need for knee replacement surgery.
A small study by the Society of Interventional Radiology found that inserting micro-particles into small blood vessels around the knee reduced pain and improved function. The tiny micro-particles — spheres about a tenth of a millimeter in size — are made from a synthetic gel-like material. The micro-particles are inserted using a catheter run through a pinhole-sized incision, in a procedure that lasts between 45 and 90 minutes. While the research is preliminary, they have noted some patients experienced relief of symptoms from the procedure.
For someone suffering knee pain the mere thought of exercise can be painful. For most knee problems specific exercises help rehabilitate injured tissues, strengthen weak muscles, and improve flexibility and range of motion.
A therapist who is specialized in knees can help an athlete rehab a partially torn ligament to avoid surgery. A knee therapist can also customize exercises that simulate the activity you hope to return to (e.g. golf, tennis, running) to strengthen the knee joint and lessen risk of injury. Same can be said for rehabilitating the knee after a surgical procedure to regain normal range of motion.
The non-surgical joint replacement
Thankfully, for the educated healthcare consumer there is new hope with the emergence over the last 10 years of a new specialty called “regenerative medicine” that uses the body’s own healing properties to restore a knee or hip joint so that movement is less painful. The importance of this specialty is that it buys people time with their existing knee or hip joint so they are older when they consider major joint replacement surgery.
The regenerative medicine specialist harvests fat from a person’s own body, spins it down with a centrifuge and then injects the substance back into the arthritic knee joint the same day. This condensed fat providing the necessary cushion and can help the joint cartilage begin some level of healing. Within this extricated fat are important living stem cells that provide a healing function to damaged cartilage and meniscus.
The end result is that thousands of weekend athletes are back on their feet enjoying movement without pain — the same goal as surgical knee replacement but without the scalpel. The person is able to buy 10 or 20 years with regenerative medicine to reach that age where they have a good chance of outliving the lifespan of that artificial joint. The result is one joint replacement surgery rather than several risky re-do surgeries at an older age.
Buyer beware the charlatans
One of the problems, however, is that where there is a new medical advance, there is no shortage of charlatans that move in to exploit and take advantage of those who don’t do the necessary research to find the legitimate specialists in regenerative medicine.
To that end, the FDA in 2021 put out a warning that some unscrupulous clinics are bilking healthcare consumers under the tag of “regenerative medicine” when they are not providing any competence or specialization in that profession. The FDA warns that these charlatans are injecting dead stem cells harvested from other sources and charging patients exhorbitant fees for something that simply doesn’t relieve pain or provide any healing function to the joint.
With that said, the FDA also has never approved and disease-modifying drug either to provide relief from osteoarthritis, at a time when other countries have been more advanced in the use of stem cell therapy and providing helpful regenerative medicine for citizens of those countries.
There is huge demand currently in the U.S. for stem cell therapy and regenerative medicine when it is provided correctly, and FDA warning aside, that demand will continue as people try to regain movement in arthritic joints without solely depending upon a major joint replacement surgery.
There is now a growing number of respected regenerative medicine clinics and hospitals that offer stem-cell injections to relieve joint pain in a way the FDA agrees with: By extracting the body’s own bone marrow or fat, spinning it down in a centrifuge, and injecting it back the same day while the stem cells are still alive.
While the treatments are not yet covered by insurance, and the treatment can cost a few thousand dollars, thousands of these stem-cell patients have found that it works and they are back to acitivity without major surgery.
When insurance companies realize that the non-surgical option saves them the cost of joint replacement and all the associated rehab costs post surgery, they too will be lining up to endorse and pay for the non-surgical joint replacement option.
Consequently, the burden is on the patient to search for a reputable regenerative medicine center that can provide a non-surgical solution to their damaged knee or hip joint while they buy time to delay the need for that surgical artificial knee or hip joint replacement.
Rather than using outside drugs, or injecting outside substances, the concept of “Regenerative Medicine” is the umbrella term for advanced methods of reversing tissue damage and REGENERATING the body by using the body’s OWN HEALING SUBSTANCES.
The term “stem cell” has varied connotations. Related to orthopedics, stem cell treatment is essentially using what cells are already in your own body, only increasing the effectiveness of your own cells.
Why a person might explore regenerative medicine and stem cell treatment over knee replacement surgery?
Plasma is the clear portion of the blood in which all the other blood components such as platelets, red blood cells and white blood cells travel.
Platelets are part of the blood that circulate around the body ready to help stop the bleeding should you have a cut, broken bone or injury that bleeds internally. Besides containing clotting factors, the platelets release growth factors and proteins that help start the healing process of arthritis knees. PRP contains a concentrated amount of platelets that release potent quantities of these growth factors and proteins to stimulate a robust healing response.
Platelet rich plasma, commonly referred to as PRP, is the patient’s own human blood that is spun down in a centrifuge and separated producing a concentration of platelets above the natural values commonly found in their blood. Platelet rich plasma can have as much as eight times more than the normal amount of platelets.
The centrifuge is used to remove red blood cells to create a plasma that has a greater concentration of growth factors than normal blood. PRP has been used in a variety of fields over the years, including plastic surgery, sports medicine and dermatology. Some professional athletes have found relief from tendonitis and overuse syndrome through PRP. The goal of PRP therapy is to enhance the body’s natural ability to repair itself to speed healing and shorten recovery time from muscle, ligament, tendon and joint injuries.
Platelets are the clotting cells within human blood that have great potential in boosting the healing of damaged muscles, tendons, and ligaments. These platelets contain natural growth hormones and proteins that tell your tissues to increase rebuilding to enhance your recovery and help stop pain symptoms.
This subsequent concentration of platelets from the patient’s own blood is then injected back into the person at the site of injury. This platelet rich plasma can then aid healing. PRP can be especially helpful for long-standing chronic injuries that have taken a long time to heal. Injecting concentrated platelets at the site of injury can accelerate the body’s own healing response.
There are some conflicting studies about the value of PRP, and which type of centrifuges may produce the optimal plasma. No studies to date have documented any adverse effects associated with PRP. So in that sense, there is no downside to the therapy. Because the injected platelets are produced from a person’s own body, there typically is no issue related to rejection or transmitting disease.
Typically, the candidate for PRP has failed conservative treatment including rest, pain medication and physical therapy. However, some patients pursue PRP as an initial treatment to speed up healing. PRP can benefit patients with painful arthritis or tendonitis in the joints. PRP can also be effective for muscle injuries, meniscus and ligament injuries.
A person undergoes PRP therapy in the physician’s office. The patient is instructed to stop all anti-inflammatory medication or steroids at least one week beforehand as these medications negatively affect platelets.
A small amount of blood (two tablespoons) are drawn from the patient’s arm. This blood sample is then placed into a centrifuge which spins the blood down so the heavier parts sinks to the bottom. Platelets and white blood cells spin out above this bottom layer and these concentrated platelets are collected and used for the injection.
Anesthesia is not necessary. A local numbing medication like lidocaine or marcaine may be used to decrease the pain at the injection site. The whole PRP treatment process typically takes less than one hour.
PRP does not provide instantaneous relief from symptoms. Growing new tissue and healing injured joints can take one to three months. But for those people who have seen their healing process stall, PRP can jumpstart the body’s own healing process.
There is great variability in the success of PRP based on the experience of the physician specializing in PRP, the type of centrifuge used, and selection of the ideal patient who can benefit from PRP.
Many famous athletes — PGA’s Tiger Woods, NBA’s Kobe Bryant and Steph Curry, MLB’s Alex Rodriguez, tennis star Rafael Nadal, and several others — have received PRP for various problems such as sprained knees and chronic tendon injuries.
As we grow old, our joints and back become more susceptible to injury. For example, arthritis and muscle/tendon injuries can arise from the loss of special cell types in the body.
Stem cells are a key component of regenerative medicine because they open the door to new clinical applications and therapies. Through a process called differentiation, stem cells have the ability to develop into many different types of cells.
Researchers are studying a variety of stem cells, including adult and embryonic stem cells. Each type of stem cell has unique qualities, with some being more versatile than others.
Adult stem cells develop from various tissues in the human body. Adult stem cells are referred to as multi-potent cells meaning they can develop into multiple cell types, but not all cell types in the human body.
Embryonic stem cells are developed from pre-implantation embryos and are unique because they can develop into all cellular types and tissues in the body. Embryonic stem cells also self-renew indefinitely.
Regenerative medicine therapies begin with the patient’s own cells that are reprogrammed in a laboratory to give them certain characteristics, and delivered back to the patient to treat a specific condition.
When stem cells are injected into an arthritic joint or injured tendon or ligament, they attach to the areas of damaged tissue to initiate the healing process.
Bone marrow was the first source of stem cells. Currently, however, fat tissue has become the preferred source of stem cells. Fatty tissue is one of the richest sources of stem cells with a higher concentration of stem cells than bone marrow.
Secondly, stem cells sourced from bone marrow age faster and are less effective for healing as a person ages. Thirdly, obtaining stem cells from fat is a simple procedure with minimal discomfort. Harvesting stem cells from within a person’s bone is much more invasive and painful.
Stem cell therapy is performed in the office. With stem cell treatment, the orthopedic specialist uses liposuction to remove fat from the patient’s own belly region. This is usually painless and takes only a few minutes. Because only about 4 tablespoons of fat are removed, there is no noticeable cosmetic difference to the site where the fat has been harvested.
This fat is then spun down in the office lab to create stem cells that are then re-injected into the painful joint. In a sense, stem cell treatment is essentially using the body’s own natural healing properties, but condensing it into a stronger dose and applying it to the body’s injured site to accelerate healing.
The fat is then transferred to a sterile device that reduces the size of the fat clusters and further breaks up the fat tissue. The tissue is rinsed with sterile saline to remove blood and oil residues.
This solution is then prepared for injection to the site of the injured joint or ligament. All injections are performed using ultrasound guidance to ensure accurate delivery of the stem cell treatment to the area of injury. In some cases, a topical or injected anesthetic may be used to decrease pain related to the injection.
The stem cells then work directly at the site of injury, or on degenerative tissue to greatly accelerate the natural healing process.
When stem cells are injected into an arthritic knee, they attach to the areas of damaged tissue inside the knee. The stem cells are able to sense the microenvironment of the knee and determine what kind of cells to grow and what molecules are needed to enhance tissue healing. The stimulated stem cells begin to grow new cells and also act as your body’s own natural drug store producing and releasing the right combination of growth factors and proteins to stimulate healing and new growth of knee cartilage, tendon and other injured tissues.
While stem cells over the last 10 years stimulated a wide debate, the reality is that the therapy has become very mainstream, and is used by many professional athletes to accelerate healing so they can return to their sport.
For example, researchers at the Mayo Clinic conducted the world’s first prospective, blinded and placebo-controlled clinical study to test the benefit of using bone marrow stem cells for arthritic knee pain. It is the first time stem cells have been tested in such a rigorous fashion. The findings in The American Journal of Sports Medicine found that patients not only had a dramatic improvement in the knee that received stem cells, but also in their other knee, which also had painful arthritis but received only a saline control injection. Each of the 25 patients enrolled in the study had two bad knees, but did not know which knee received the stem cells.
A recent study showed that stem cell therapy for knee arthritis resulted in a 58-68% improvement in pain and 67-83% improvement in function one to two years after treatment. One study from 2014 showed that stem cell injections given after surgery to remove torn knee cartilage showed evidence of cartilage regeneration and lessened pain.
There is a tremendous amount of misleading information about “stem cell” treatments. Some physicians or chiropractors use amniotic, placental or umbilical tissues. However these are not stem cell procedures as they do not contain any live cells. Also they are not stem cells from your own body, so you are injecting an outside substance into the joint.
Proper stem cell treatment harvests the cells from the patient’s own fat, which can contain 500–1000 times the concentration of stem cells than a sample collected from bone marrow.
Consequently, a person needs to explore in depth how stem cell treatment is being performed at a clinic, and most importantly, WHERE are the cells coming from, and if they are live or dead cells. Dead stem cells are worthless.
Stem cell treatment for knees is noninvasive, and studies suggest that side effects are minimal. After the procedure, some people may experience temporary increased pain and swelling. However, the overwhelming majority of people who get stem cell injections have no adverse side effects.
The method where stem cells are harvested from your own body, dramatically reduces the risk of any serious side effects. However, there are various ways of harvesting and processing the stem cells, which likely affects the various success rates of the published studies.
Again, before receiving any stem cell treatment, it’s best to learn as much as you can about the physician and the stem cells they are using. There can be wide variation in success based on the physician and how experienced they are with stem cell treatment of knee pain.
Fees can vary greatly for stem cell treatment of knee pain, but the procedure can range around $2,000 to $4,000 per treatment for knee arthritis. Insurance companies may deny coverage, although in some cases they may cover it when done along with another, established procedure.
While the Alternative Medicine treatments listed here typically do not change the structure of the knee, they can relieve some pain symptoms without dependence on drugs — with virtually no side effects if done correctly. Some of these treatments may be more effective on some people than others.
Acupressure is an ancient Chinese form of therapy where pressure is applied to the body in order to increase blood circulation and relieve pain. This unique form of massage can relax muscles and compress nerve fibers that cause pain. If you are interested in experimenting with this form of therapy, you can either find a professional acupressure therapist or simply go to the bookstore and find a book that will tell you how to try the techniques at home by yourself or by a partner.
While acupuncture has limited value for many orthopedic injuries, it may be a way of avoiding a surgery if that is your goal.
During acupuncture, hair-thin needles are inserted into various parts of the body and are stimulated to alleviate pain in many forms including but not limited to nausea, dental pain, muscle pain, menstrual cramps, and pain from osteoarthritis. This 3000-year-old Chinese art gained credibility in the western world in 1997 when the National Institutes of Health declared it to be effective for some ailments.
The Chinese believed that by balancing the positive and negative energy in the body, pain relief can be achieved. They found acupuncture to be an effective resource to achieve that balance. Other modern-day doctors believe that acupuncture stimulates pressure points thus releasing relaxing endorphins. Whatever the case may be, acupuncture provides relief to many people suffering from pain.
If you decide to try acupuncture, be sure to have a licensed professional administer the treatment. Also, get a physician’s referral for an acupuncturist close to you. An acupuncturist should be certified by the National Commission for the Certification of Acupuncturists. You can obtain a list of certified specialists in your area by calling the American Association of Acupuncture and Oriental Medicine.
Spas and whirlpools are sometimes used to improve circulation and relieve chronic pain from joints. Different therapy uses different temperatures of water. Cold water reduces inflammation and warm water improves circulation.
The other aspect of working with a hydrotherapist, is that by doing exercises in a pool, the water creates an artificial weightlessness. So a very overweight person who would otherwise find any knee exercise painful because of their body weight, can find that doing exercises in a pool is tolerable.