The Analyst™

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  Knee Pain  
 
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Conditions that suggest it | Contributing risk factors | Other conditions that may be present | Recommendations

 

Acute knee pain usually results from overuse, poor form during physical activity, not warming up or cooling down, or inadequate stretching. Simple causes of knee pain often clear up on their own with self care. Chronic knee pain can be a result of injury or disease. Being overweight can put you at greater risk for knee problems.

Knee pain can be caused by:

  • Arthritis - including rheumatoid, osteoarthritis, and gout, or other connective tissue disorders like lupus.
  • Bursitis - inflammation from repeated pressure on the knee (like kneeling for long periods of time, overuse, or injury).
  • Tendinitis - a pain in the front of your knee that gets worse when going up and down stairs or inclines. Happens to runners, skiers, and cyclists.
  • Baker's cyst - a fluid-filled swelling behind the knee that may accompany inflammation from other causes, like arthritis. If the cyst ruptures, pain in the back of your knee can travel down your calf.
  • Torn or ruptured ligaments or torn cartilage (a meniscus tear) -- can cause severe pain and instability of the knee joint.
  • Strain or sprain - minor injuries to the ligaments caused by sudden or unnatural twisting.
  • Dislocation of the kneecap.
  • Infection in the joint.
  • Knee injuries - can cause bleeding into your knee, which worsens the pain.
  • Hip disorders - may cause pain that is felt in the knee. For example, iliotibial band syndrome is injury to the thick band that runs from your hip to the outside of your knee.
  • Foot problems can result in poor tracking of the knee cap with pain.
  • Less common conditions that can lead to knee pain include bone tumor and Osgood-Schlatter disease

 

 
 

Conditions that suggest Knee Pain:
 
 
Symptoms - SkeletalCounter-indicators:
  Absence of knee pain
 
 

Risk factors for Knee Pain:
 
 
Autoimmune  Ankylosing Spondylitis

Musculo-Skeletal

  Osteoarthritis
  Rheumatoid Arthritis
 
 

Knee Pain suggests the following may be present:
 
 
Musculo-Skeletal  Joint Pain, General
 
 

Recommendations for Knee Pain:
 
 
Animal-based  Glucosamine / Chondroitin Sulfate
 A scientific review released by HHS' Agency for Healthcare Research and Quality (2007) concludes that evidence of benefit is lacking for many common ways of treating osteoarthritis of the knee, including popular dietary supplement ingredients, a common surgical procedure, and injected preparations.

The review found that glucosamine and chondroitin, over-the-counter dietary supplement ingredients that are used widely because of their purported benefits to relieve knee pain caused by osteoarthritis and improve physical functioning, appear to be no more effective than placebos. A placebo is a harmless substance given to selected patients in a clinical trial that looks like the real drug or injection being studied, but which has no medical effect.

The review, which was requested and funded by HHS' Centers for Disease Control and Prevention, also failed to find convincing evidence of benefit from arthroscopic surgery to clean the knee joint with or without removal of debris and loose cartilage.

Published studies generally report that injections with hyaluronan preparations (substances that are intended to improve lubrication of the knee joint) improve scores on patient questionnaires used to measure pain and function. However, the evidence is uncertain because of variation in study quality and difficulty determining whether changes in scores translate into real clinical improvements for patients.

"Millions of Americans seek relief from the pain and reduced mobility caused by osteoarthritis of the knee," said AHRQ Director Carolyn M. Clancy, M.D. "However, they should work with their clinicians to decide the best course of treatment for them based on what has and has not been proven to work."

Osteoarthritis is a widespread, costly disease that wears away the cartilage cushioning the knee joint, causing pain and reducing mobility. Arthritic diseases, which include osteoarthritis, affect an estimated 46 million people in the United States, and at age 64 and older, one in 10 Americans is estimated to have osteoarthritis of the knee. Osteoarthritis and related arthritic conditions cost more than $81 billion a year in medical care, lost wages, and other expenses.

The authors, who were led by David J. Samson, M.S., associate director of the AHRQ-supported Blue Cross and Blue Shield Association Evidence-based Practice Center in Chicago, reviewed findings from 53 randomized clinical trials of glucosamine, chrondroitin, and injections with hyaluronan preparations and 23 studies of arthroscopy. The review scrutinized individual studies concerned with these treatments' effects as well as meta-analyses that analyzed the combined evidence of groups of studies.

According to authors, better quality randomized clinical trials are needed to clarify whether these treatments are beneficial. However, given the aging of the population and increasing prevalence of obesity - both risk factors for osteoarthritis of the knee - "research on new approaches to prevention and treatment of osteoarthritis of the knee should be a high priority."

There was a study done using a prescription preparation of hyaluronan (pronounced hyal-u-ROE-nan). For more about the positive results, please see the link between Knee Pain and Hyaluronic Acid.

A two-year study was conducted called the Glucosamine-chrondroitin Arthritis Intervention Trial (GAIT) to know whether glucosamine was effective or not. And now, the results are in. GAIT measured the effects of taking glucosamine alone, chondroitin alone, a glucosamine-chondroitin combination, and celecoxib alone against placebo in 1,583 people with either mild or moderate-to-severe pain from knee OA.

Results show that the combination of glucosamine and chondroitin is better than placebo, but the benefits appear to depend on pain severity.

Mild pain. The glucosamine and chondroitin combination did not show effectiveness for people with mild pain. Sixty-three percent of those with mild pain responded to the glucosamine and chondroitin combo, and 62 percent responded to the placebo.

Moderate-to-severe pain. Of the people with moderate-to-severe knee OA pain, 79 percent who took the glucosamine-chondroitin combo experienced pain relief, compared with 66 percent who took glucosamine alone, 61 percent who took chondroitin alone, and 54 percent who took placebo. “The people with moderate-to-severe pain who took glucosamine and chondroitin sulfate together showed significant improvement in their knee pain,” says lead author Daniel O. Clegg, MD, professor of medicine and chief of the division of rheumatology at the University of Utah School of Medicine in Salt Lake City, one of 16 rheumatology centers involved in the NIH-sponsored GAIT.

The results of a second smaller trial, called the GUIDE trial, are also in. Conducted in Spain and Portugal, the six-month-long study measured the effects of a 1,500-mg daily dose of glucosamine against a 3,000-mg daily dose of acetaminophen (Tylenol) or placebo in 318 people with knee OA. The researchers concluded that glucosamine relieved pain significantly better than the acetaminophen or placebo.

2014. Dr. C. Kent Kwoh enrolled 201 people with mild to moderate pain in one or both knees in his study. The participants, aged 35 to 65, were recruited from physician offices and the University of Pittsburgh Arthritis Registry.

They were split into two groups:

Those treated daily with 1500 mg of glucosamine hydrochloride in a 16-oz bottle of diet lemonade.
Those treated with a placebo.

During a 24-week period, the participants were followed up with phone calls every four weeks. At the end of that period, they all underwent an MRI to assess the cartilage damage in their knees.

Researchers assessed both groups on four things: knee pain, degradation of cartilage, bone marrow lesions, and the excretion of CTX-11 in urine.

Researchers discovered that there was no difference in any of those characteristics between the group that took the glucosamine and the group that had the placebo.

The urinary excretion of C-telopeptdes of type II collagen (CTX-11) is a predictor of cartilage destruction. Researchers found that there was no decrease in that either.

“Our study found no evidence that drinking a glucosamine supplement reduced knee cartilage damage, relieved pain, or improved function in individuals with chronic knee pain,” concluded Dr. Kwoh in his study.

Diet

  Weight Loss
 Very attainable weight loss goals are sufficient to reduce pain and therefore motivate overweight patients with knee osteoarthritis to keep that weight off, according to research presented (November 13, 2006) at the American College of Rheumatology Annual Scientific Meeting in Washington, DC.

Weight gain dramatically multiplies the pounds of pressure and loading forces on the knee structure. Because this pressure leads to more wear and tear over time, body weight is considered one of the significant contributors to the onset and progression of knee osteoarthritis. Conversely, weight loss can relieve those realities.

Now, a long-term weight loss program has demonstrated that even modest weight loss contributed to improved quality of life in 30 mildly obese patients, and the resulting reduction in pain was so dramatic as to motivate their keeping the weight off.

Drug

  Conventional Drugs / Information
 Please see the link between Knee Pain and Hyaluronic Acid.

Physical Medicine

  Physical Supports

Skin

  DMSO Topically
 Double-blind and other controlled studies have found a 25% DMSO gel effective for pain relief in osteoarthritis of the knee.

Surgery/Invasive

  Prolotherapy
  Hyaluronic Acid
 Physicians have injected hyaluronic acid directly into the synovial fluid in the knee as a treatment for osteoarthritis for the last 20+ years. There are many peer-reviewed articles written on the use of hyaluronic acid for this purpose. Please see the link between knee pain and Glucosamine.

In a meta-analysis of eight hyaluronan trials involving 971 patients, outcomes in patients treated with hyaluronan were superior to outcomes in patients treated with placebo at the end of the treatment cycles and after six months. [Ann Rheum Dis 1998;57:pp. 637-40]

Treatment is expensive. For a package of three prefilled syringes of Synvisc, the average wholesale price is $620.00. Third-party reimbursement is variable, but Medicare and most insurance companies now cover viscosupplementation. A product called Synvisc-One is now available which achieves a similar result in just one injection.

A study of Synvisc-One (hylan G-F 20) was conducted in 253 patients in six countries outside the United States. Patients were at least 40 years old, had mild or moderate knee OA and were experiencing moderate to severe knee pain. Patients in the study were given either:

•A single injection of Synvisc-One
•An injection of salt water (called a "saline control")

The goal was to determine how well Synvisc-One reduced knee pain during five common activities (walking, going up stairs, etc.). Doctors evaluated the patients at weeks 1, 4, 8, 12, 18 and 26.

Results: The study showed that patients who received Synvisc-One had significantly less pain over six months and felt significantly better than the saline control group. Specifically, 71% of patients reported pain relief with Synvisc-One. Most patients reported pain relief starting at week four.

Side effects were also tracked. The types and frequencies of side effects were similar between the two groups. The most common side effects were knee pain, stiffness, and swelling or fluid buildup in or around the knee. These were generally mild to moderate and did not last long. Other side effects, such as rash, may also occur. Side effects were generally mild to moderate and did not last long. No serious side effects were seen in the injected knee during the study that were related to the use of Synvisc-One.

Before trying Synvisc-One or SYNVISC, tell your doctor if you are allergic to products from birds—such as feathers, eggs or poultry—or if your leg is swollen or infected. Synvisc-One and SYNVISC are only for injection into the knee, performed by a doctor or other qualified health care professional. Synvisc-One and SYNVISC have not been tested to show pain relief in joints other than the knee.

Synvisc-One is the same formulation as SYNVISC. The only difference is that Synvisc-One is provided with one injection, compared to the three injections required for SYNVISC. Both treatments can provide up to six months of pain relief.

Here is the home page of this product. This one-time injection costs upwards of $400.00 wholesale, so prolotherapy should be considered for those who can not afford this.

An FDA review of this product, also called Genzyme, at that time, can be found here.

  Surgery
 A review in 2007, which was requested and funded by HHS' Centers for Disease Control and Prevention, failed to find convincing evidence of benefit from arthroscopic surgery to clean the knee joint with or without removal of debris and loose cartilage.
 
 


KEY
Strong or generally accepted link
Very strongly or absolutely counter-indicative
May do some good
Likely to help
Highly recommended







GLOSSARY

Acute:  An illness or symptom of sudden onset, which generally has a short duration.

Arthritis:  Inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances, or other causes. It occurs in various forms, such as bacterial arthritis, osteoarthritis, or rheumatoid arthritis. Osteoarthritis, the most common form, is characterized by a gradual loss of cartilage and often an overgrowth of bone at the joints.

Bursitis:  The bursa is a fluid-filled pad that allows your muscles to easily slide over other muscles and bones. Bursitis occurs when this pad becomes inflamed. It usually occurs when you overuse or injure a specific joint, but it can also be caused by a bacterial infection. Symptoms include pain and inflammation around joints such as the elbow, hip, shoulder, big toe, ankle or knee.

Cartilage:  Specialized fibrous connective tissue that forms the skeleton of an embryo and much of the skeleton in an infant. As the child grows, the cartilage becomes bone. In adults, cartilage is present in and around joints and makes up the primary skeletal structure in some parts of the body, such as the ears and the tip of the nose.

Chronic:  Usually Chronic illness: Illness extending over a long period of time.

Cysts:  A closed pocket or pouch of tissue; a cyst may form within any tissue in the body and can be filled with air, fluid, pus, or other material. Cysts within the lung generally are air filled, while cysts involving the lymph system or kidneys are fluid filled. Cysts under the skin are benign, extremely common, movable lumps. These may develop as a result of infection, clogging of sebaceous glands, developmental abnormalities or around foreign bodies.

Gout:  A disease characterized by an increased blood uric acid level and sudden onset of episodes of acute arthritis.

Osgood-Schlatter Disease:  One of the most common causes of knee pain in young athletes. It causes swelling, pain and tenderness just below the knee, at the top of the shin bone (tibia). It occurs mostly in boys who are having a growth spurt. One or both knees may be affected.

Rheumatism:  General term applied to conditions of pain, or inability to articulate, various elements of the musculoskeletal system.