A Comprehensive Approach: Multidisciplinary Care for Knee Pain in Singapore
Pain is often the presenting symptom of knee degeneration. The article brings to light the different causes of knee pain, bearing in mind the nature of the local population, which predisposes them to early onset of knee degeneration. While exercise-induced pain and ligamentous injuries are common in the young, arthritis is the commonest cause of knee pain in the elderly population. The authors rightly pointed out that even though it is an often benign condition, knee pain frequently impairs the quality of life as it limits mobility, leading to systemic deconditioning and predisposing to cardiovascular disease. In the long run, the inability to walk frequently results in the elderly becoming more dependent on their relatives, a burden which is keenly felt by both parties. These are real issues to the local population and to the caregivers of patients suffering from knee pain. From a physiological perspective, knee pain has far-reaching effects on distal muscle and proprioceptive function, which can be a barrier to proper rehabilitation. This makes the delegation of appropriate treatment an important but often challenging task.
Overview of knee pain in Singapore
In the general working population, knee pain may lead to decreased job performance or maybe even work loss. The housewife or caregiver may have impaired functional ability due to knee pain, and this would affect the elderly and the family as a whole.
Why is knee pain such a significant problem in Singapore? Knee pain affects many areas of the lives of an individual. In the very active population such as those involved in the armed forces, police force, fire services, sports, and martial arts, knee injuries are common due to accidents and injuries sustained while in active service or sports. This results in a change of vocation or early retirement. These injuries may lead to persistent knee pain and osteoarthritis in the long run.
We are living longer, and this increases the risk of developing chronic joint and knee pain. In a local study focusing on knee pain in the elderly, the prevalence of knee pain in those aged 60 years and above ranged from 25% to 56%.
Another study looked at adults over 40 years old and showed that radiographic knee osteoarthritis was prevalent in the Chinese, Malay, and Indian ethnic groups with a rate of 50.0%, 59.9%, and 40.5% respectively. Furthermore, the pain and functional disability faced by these individuals with radiographic knee osteoarthritis was not to be underestimated, as it was similar to or worse than that experienced by patients in the US and Europe seeking joint arthroplasty.
Knee pain is a common symptom affecting people of various age groups in Singapore. In a local study looking at the adult population, the overall prevalence of chronic knee pain was 21.5%. This was taken from a survey of over 3,000 adults on chronic pain. Knee pain was reported to be the most common form of chronic pain with significant impact on the quality of life in Singapore.
Importance of multidisciplinary care for knee pain
Given the complex nature of knee pain, the ideal would be to have services to manage these patients with multiple knee and health problems in a seamless and integrated manner. This is where a multidisciplinary model of knee care would be most beneficial.
Addressing multiple health conditions also means that patients can develop multi-organ adverse events from utilizing different medications. This also includes monitoring and prevention of adverse medication effects on the knee joint and coordinating medication changes to optimize or avoid worsening of knee conditions. Essentially, it would be dealing with a host of problems that a patient with knee pain may have, factoring in their overall health and potential effects on the knee joint.
A significant proportion of patients with knee pain have multiple co-existing problems requiring management, not just limited to isolated knee osteoarthritis. These patients often have other age-related conditions such as hypertension, diabetes, high cholesterol levels, and heart disease. Often, medications prescribed by different subspecialty doctors may have potential side effects on the knee joint or worsen co-existing knee conditions. Caring for these patients involves addressing their various health issues, which may be related, associated, or unrelated to their knee pain. This adds to the complexity of managing knee pain and the decision-making process.
Healthcare costs are projected to rise in the coming decades due to an aging population. Musculoskeletal conditions have been shown to be a significant cause of disability in the elderly. Hip and knee pain and their related joint osteoarthritis are highly prevalent and are leading causes of impaired quality of life, accounting for high healthcare expenditure. Joint replacement surgery is one of the most frequent and costly musculoskeletal procedures. It is also projected that the burden of knee and hip osteoarthritis, in terms of disability adjusted life years, will continue to rise dramatically in the coming decades.
Diagnosis and Assessment
The first step to the assessment of your knee pain is a comprehensive history. Coming prepared will ensure that you are able to convey as much information as possible. Consider the characteristics of the pain, how it started, did you hear a pop or snap at the time of injury, was it associated with any swelling or giving way, is it worsening or improving, your functional limitations, and any positions or activities which aggravate or relieve the pain. It may be helpful to discuss these questions with a family member as well, as they may recall specific events better than you can. Writing dot points for each of these questions will provide a good framework for the discussion with your knee pain doctor Singapore.
Knee pain is a common problem with many possible causes. It can originate from any of the bony structures compromising the knee joint (femur, tibia, fibula), the kneecap (patella) or the ligaments and cartilage (meniscus). There are some direct correlations of specific complaints to certain diagnoses, however more often it is difficult to determine a single diagnosis as the cause of the pain. It is important to consider the characteristics of the pain, onset and mode of injury, your individual activity demands and any associated symptoms. The following conditions are common causes of knee pain, although this is not an exhaustive list, and in many cases more than one problem may be present.
Common causes of knee pain
When a patient presents with knee pain, more often than not, the cause can be traced back to issues with any of the structures specific to the knee joint. Within this, whether the patient has had any form of trauma event to the knee in the recent or even sometimes distant past can be an important differentiating factor. Common causes of atraumatic knee pain can be split into anatomic or biomechanical in nature. Anatomic causes manifest as localized damage to a certain structure within the knee, such as a ligament tear or meniscal lesion. Patellofemoral syndrome and osteoarthritis are common examples of degenerative changes which can also result in atraumatic knee pain. Biomechanical changes which alter the forces through the knee joint can often cause diffuse pain. This is typified by somebody with flat feet who has pain from altered lower limb alignment. A thorough understanding of the patient’s symptoms and any relevant events is often the most useful tool a doctor has in diagnosing the cause of knee pain. Following a clear understanding of the patient’s knee pain as a problem, the clinician’s role is to then clarify the exact cause. Often, the diagnosis is quite obvious from the history and examination findings. Somebody with an acute anterior cruciate ligament tear during a skiing injury, for example, usually feels a pop in the knee, has immediate swelling, and comes to the doctor with knee instability. An x-ray is a useful initial investigation for recent onset trauma with the likely presence of a fracture.
Diagnostic procedures for knee pain
Similarly to this, injecting local anaesthetic and/or steroids into the knee can be both a diagnostic and treatment intervention. A significant amount of pain relief following injection of local anaesthetic into a particular part of the joint suggests that this is the cause of pain. Steroids have the potential to provide longer lasting relief of symptoms and reduce inflammation. The anti-inflammatory effect can sometimes give further information about the diagnosis. However, there is often a limit to the number of injections that can be given and often the pain relief is fleeting. Both of these procedures are relatively quick and cheap and carry little risk.
Joint aspiration involves using a needle and syringe to extract fluid from the knee joint which can then be sent to the laboratory for analysis. It can be useful in differentiating between inflammatory and non-inflammatory arthritis, having implications if it is then decided to commence treatment with disease modifying medication. It can also be useful if there is a suspicion of an acute infection within the joint, in which case the fluid can also be sent for culture. This can be a painful procedure and can sometimes be difficult in overweight individuals or those with a large effusion.
There are a myriad of potential diagnoses for knee pain, many of which can present in similar ways or existing concurrently making diagnosis difficult. Although in some cases clinical examination alone may be sufficient in reaching a diagnosis, in many cases it will be necessary to undergo further investigations. Commonly used diagnostic procedures include joint aspiration, injecting local anaesthetic and/or steroids, and various forms of imaging.
Treatment Options
For pain due to chronic arthritic conditions, it is necessary to move on to more specific treatments that can help alleviate pain. Changes to lifestyle, physiotherapy, and the use of braces can be very effective in some cases. A corticosteroid injection into the joint can often provide good pain relief and reduce inflammation, although it is not effective for all patients. Viscosupplementation is another form of injection therapy that can be beneficial for some patients with early osteoarthritis.
Usually, the initial treatment of knee pain caused by a minor injury or a sudden onset of an arthritic condition involves self-help measures. These are useful in cases where the doctor cannot be seen immediately. PRICE regime can be used for most injuries – P is for Protect, R is for Rest, I is for Ice, C is for Compression, and E is for Elevation. Anti-inflammatory medications can be helpful, and some patients find significant relief from joint supplementation. Weight loss helps reduce the load across the knee joint and can be helpful in slowing the progression of arthritis.
Knee pain is a very common complaint that affects people of all ages. Knee pain may be the result of an injury, such as a ruptured ligament or torn cartilage. Some medical conditions, including arthritis, gout, and infection, can also lead to knee pain. Nonsurgical management of knee pain recommends decreasing pain and improving function. It is not so much about ‘curing’ knee pain as it is about managing it and keeping it from interfering with your life.
Non-surgical interventions for knee pain
The demonstrated effectiveness of these non-surgical interventions can assist physician decision-making and consultancy with knee pain sufferers.
Patellofemoral knee pain sufferers may benefit from exercise based on a recent consensus statement, which suggested that hip and knee strengthening exercises and foot orthoses are most effective in this group of patients. However, the use of foot orthoses needs to be balanced with the lack of proven effectiveness and high cost in this group of patients.
Post-exercise weight loss, whether individually prescribed or as part of a supervised program, can further enhance the effects of exercise on knee pain. A recent systematic review and meta-analysis of the effects of physiotherapy in knee osteoarthritis suggested that there are significant short-term improvements in pain and function, and moderate-level evidence exists to support the role of manual therapy in this group of patients. Tai chi has also been shown to have moderate improvements on knee pain and function in patients with knee osteoarthritis in a recent meta-analysis.
High-level evidence exists to support the role of a number of different exercise interventions in the treatment of knee pain. Land-based therapeutic exercise has shown to reduce pain and improve function in patients with knee osteoarthritis. This may include strengthening exercises, active range of motion exercises, and weight-bearing endurance exercises. Aerobic exercises have also been shown to have very positive effects on pain and function in knee osteoarthritis, and there is evidence to support aquatic-based exercise in this group of patients as well.
Weight loss is a significant factor in overweight knee pain sufferers and has been shown to have a strong relationship with symptomatic improvement. Various studies have indicated that weight loss has a direct correlation with reduction in joint loads, and therefore effective weight loss should be advised for overweight knee pain sufferers.
Specific to patellofemoral knee pain, taping of the patella has been shown in some studies to have short-term benefit in pain relief and improved function, and it is quite a low-cost intervention for some patients. There is no current evidence to support the use of braces or shoe insoles, and a recommendation cannot be made for these interventions for knee pain sufferers.
Muscle strength is known to be a significant factor in knee pain and its progression. Weak quadriceps have been extensively researched in relation to knee pain, and it has been determined that strengthening these muscles can have a significant effect on pain reduction. This is an essential foundation in any exercise regime or knee pain intervention.
Surgical options for knee pain
Surgical treatment options for knee pain are usually considered when the knee pain is severe and is affecting the patient’s quality of life. It is also considered in patients where other treatment options have failed. There are various surgical options available depending on the diagnosis. Common surgical procedures include meniscectomy, ACL reconstruction, chondroplasty, and total knee replacement. Surgery may have high success rates, especially in meniscectomy and ACL reconstruction, but there will always be a number of patients who do not respond favorably to the surgery. Total knee replacement is often considered in the elderly with severe knee OA and has shown to improve quality of life in patients with successful operation. However, there have been studies to show that those with advanced age and poorer preoperative health may not benefit from total knee arthroplasty in the long run. In addition, surgical procedures are associated with complications and often require a long postoperative rehabilitation phase. Thus, it is important to consider the potential benefits and adverse events before deciding on surgical intervention. This is often best discussed with the orthopedic surgeon. With regards to the recent pandemics of diseases, it is crucial to weigh the risks of contracting the infection during admission against the benefits of the surgery. Some procedures, like elective total knee replacement, may be best to postpone to a later date.
Rehabilitation and Follow-up
Ultimately, the concept of knee rehabilitation is to re-establish the normal function of the knee. This can only be achieved by educating the patient, implementing an effective exercise program, addressing modifiable risk factors, and the development of an active maintenance program. Patient education should be the first step in the rehabilitation process. It is important for the patient to understand their injury, realize the healing time involved, and become aware of the importance of returning the knee to a normal level of function. The patient may have been given a variety of information/terminology about their injury, and it is important that they understand what it all means. Clear explanation by the physician and the provision of written information may help to clarify any misunderstandings. This will also provide an opportunity for the patient to question the health professional.
Rehabilitation exercises for knee pain
Last but definitely not least are proprioceptive exercises. These attempt to make the knee more ‘aware of its place in space’ and are vital for a successful return to activity/sport and prevention of re-injury. There are various exercises that can range from using a wobble board to single-legged mini squats, but they all work on the same principle of augmenting sensory input to the knee and appropriate motor output.
Barefoot gait training can also be used to improve neuromuscular control of the lower extremity. Patellofemoral pain patients have been shown to walk with decreased stance phase knee flexion and eccentric vastus medialis oblique activity, resulting in increased lateral tracking or tilt of the patella. A study has shown that following 8 weeks of barefoot gait training, there were significant increases in both reaction time of the vastus medialis oblique and onset of knee flexion during stance. Similar improvements have been seen in patients rehabilitating from anterior cruciate ligament (ACL) reconstruction.
For the early stages after injury or surgery, protection/rest, ice, compression, and elevation (PRICE) can help limit swelling and protect the injured knee. Weight bearing strength and range of motion should also be addressed. One study showed that knee motion began improving at 9 days and strength at 4 days using electrical muscle stimulation. Strengthening exercises of the quadriceps are crucial, as the loss of strength and mass in the quadriceps can be as much as 20-40% with arthrogenic muscle inhibition (AMI) following knee injuries and surgery. It is important, however, to find the right balance, as more damage can be caused by exercising too much (as muscle activation of the quadriceps is crucial for knee joint unloading) or too little (where there is no increase in strength).
Importance of follow-up care for knee pain
Primary practitioners have a responsibility to follow through and re-evaluate patients’ status after the initial treatment phase. Currently, follow-up care for musculoskeletal pain in primary care is poor. Very few patients would have been referred to a specialist as a result of the initial NSAIDs/painkillers treatment, hamstringing the specialists’ abilities to discover the root cause of the problem. If resolved, the patient is left with a relative weakness around the knee and no guidance on preventing a recurrence, leaving the knee susceptible to a new or chronic injury. If the problem still persists, an appointment to see the same GP would likely result in a second prescription of NSAIDs, various painkillers, or a different type of injection without the knowledge of the initial treatment. This ultimately hinders the patient from returning to full function by missing the opportunity to reassess and re-evaluate the initial management of the injury. For all initial treatments, following up with the patient to gauge a therapeutic response is invaluable information. This directs the therapist whether to continue, amend, or halt the current treatment to optimize the patient’s outcome. A specialist is usually given a specific referral question; however, it is not uncommon for the patient to have forgotten the details of the problem at the time of the appointment. An accurate patient history is vital to the clinician deciding on the most appropriate treatment. Finally, the growing number of surgeries in Singapore to remove intra-articular fragments or treat meniscal tears poses a higher rehabilitation requirement. This may involve consultations between the surgeon and therapist to plan the rehabilitation progress.