4 Common Causes of Knee Pain

August 19, 2013November 17, 2015 / Thomas Cohn, MD

There are many causes of knee pain and treatment is dependent on determining the exact cause. The knee has many components including multiple ligaments, tendons, cartilage, bursa, and bones. Because there are so many components, determining the problem is often difficult. Age and activity level can often be a clue to the existing problems. Younger and more athletic people have injury type problems, while older people develop issues related to degeneration. Below are four of the most common causes of knee pain:

Osteoarthritis is the most common type of degeneration that occurs in the knee. It is the progressive wear of the joint cartilage that occurs with age and use of the joint. Read more about Osteoarthritis causes and treatment.
Obesity worsens and stresses the joints even more as people age. The knee becomes chronically swollen, and painful with activity. Treatment is symptomatic – keep the knee moving and strong, and use over the counter medications for the pain as necessary. If you are obese, try to reduce your weight to relieve additional stress. When the deterioration is severe, there are orthopedic surgeries that can help including knee replacement.
Traumatic injuries to the knee include torn ligaments, meniscus tears, and tendonitis. Bony injuries also occur to the patellar and the other bones of the joint area. The anterior cruciate ligament is the most common ligament damaged in sports, caused when there is a sudden change in direction of the body. The side ligaments can also be injured in sports. These are usually treated conservatively. The meniscus is part of the cartilage in the knee and is a shock absorber. Injury to the meniscus occurs with twisting while weight bearing, and is fairly common in older active adults. Surgical repair is simple if conservative management is unsuccessful.
Bursitis & Tendonitis. Brusitis is inflammation of small sacs of fluid that cushion ligaments and muscles around the knee. This condition often resolves with rest. Tendonitis commonly occurs to the patella tendons in runners, skiers, and cyclists. This condition is also best treated with rest.

Pain in the knees is relatively common. Traumatic injuries often respond to conservative care. If not resolving, evaluation by a physician is recommended to determine the cause and best treatment options. Age related changes, such as osteoarthritis, are usually treated conservatively as long as possible. If conditions worsen, physicians can prescribe stronger medications, special joint injections, and help determine when surgery may be beneficial.

Osteoarthritis of the Knee – Treatment Options

July 17, 2013September 27, 2016 / Thomas Cohn, MD

Earlier this week, we discussed the signs and symptoms of osteoarthritis in the knee. Today we will further investigate this condition by discussing the treatment options for osteoarthritis.

Treatment of osteoarthritis of the knee includes a wide range of options, starting with lifestyle modifications, medications, and progressing to surgical management.

Always start simple. Change starts with the individual and is not magical. The most common first step is to lose excess weight so you are not stressing the joints. Change the type of activity you are doing from high impact to low impact exercise. Go from jogging to cycling and swimming, or try an elliptical. Walking is always a good alternative as well. Exercise maintains range of motion, flexibility, and health. Add in strengthening and function may also improve.

Medication Management

Medication management is the next level of care. Having a physician involved in this level is beneficial to prevent negative side affects. Natural substances you can take include:

A combination of glucosamine and chondroitin. These are natural substances found in joints. If taken orally they are supposed to promote normal joint health. Scientific studies are mixed on whether they are truly helpful, but they rarely if ever would be harmful, if early in the disease, it may be worthwhile.
Fish oil. This can help with joint lubrication.

Prescription level medication starts with acetaminophen, to aspirin and anti-inflammatories, to steroids and injectable compounds. Acetaminophen is only an analgesic and it treats pain. Aspirin and ibufrophen or naproxen, are a class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs), and can treat pain and swelling. These medications are stronger, may be taken orally and may be available as crèmes, but have many side affects and should be used with caution. Skin preparations however are very safe and may be extremely helpful.

Corticosteroids are very powerful anti-inflammatory hormones, and sometimes on a limited basis orally or as injections can be helpful in controlling pain and swelling for long periods of time. Lastly, viscosupplementation with injectable hyaluronic acid compounds is used to improve joint fluid production for periods of 3-6 months.

Surgical Options

End stage knee osteoarthritis can be treated surgically. Orthopedic surgeons can do several things from cleaning up and removing damaged tissue in the joint arthroscopically when appropriate, to replacing the knee joint. Surgical intervention is a consideration when the damage is severe, not responding to more conservative options, and otherwise when the patient is healthy enough to undergo surgery.

Osteoarthritis will occur eventually in all of us as we age. The key to control degeneration is to maintain good health habits. Keep your weight under control, excess weight will stress out your joints. Exercise, this will keep everything moving, and maintain your strength. Work with your doctor if more advanced treatments are needed.

Osteoarthritis of the Knee – Signs & Symptoms

July 15, 2013September 27, 2016 / Thomas Cohn, MD

As we age, many of us develop knee pain. One of the most common knee conditions is Osteoarthritis – slow degeneration of the cartilage of the knee.

Symptoms of Osteoarthritis

The symptoms of osteoarthritis are:

Gradual onset of stiffness in the joint, especially after sitting for a period of time or lying down
Difficulty bending and straightening the knee
Swelling and pain when first moving the knees, sitting, or kneeling
In more severe cases, the size of the knee may become larger

As we get older, joints in the body age and deteriorate. This starts as early as our twenties, and is more common when we are past forty. Historically, the body was designed to get us to between age forty and fifty. Prior to the onset of modern medicine roughly 150 years ago, disease, trauma, and natural conditions like heart problems killed us by age fifty. So as we age, there is increasing wear from normal use and trauma on our joints including our knees. Weight also often increases as we age and further stresses weight bearing joints.

Factors & Signs

Factors that contribute to osteoarthritis development are:

Age
Trauma
Weight
Genetic tendency (some families may be more prone to its occurrence)

In the doctor’s office, when we examine a knee with osteoarthritis, we usually see a large knee, maybe slightly swollen but not warm, and stiff to move. Plain X-rays will reveal a large joint, often with narrowing of the joint space especially on the inside aspect, and the joint surfaces may appear to be irregular from deterioration.

Read our follow up blog on the treatment options for Osteoarthritis.

Do Opioids Reduce Inflammation in Chronic Pain Patients?

July 3, 2013September 27, 2016 / Thomas Cohn, MD

A recent preliminary study found that inflammation in patients with chronic pain is persistent despite long-term opioid treatment.

The study was carried out by Forest Tennant, MD, director of the Veract Intractable Pain Clinic in West Covina. Dr. Tennant examined 40 patients from July 2012-October 2012. All of these patients had been receiving heavy doses of opioids to treat their chronic pain for the past 10 years.

While many patients reported improved levels of depression and function, 20% of those surveyed still had high levels of inflammation markers. Further, a number of patients had abnormally high hormone levels.

Dr. Cohn Comments

Opioids are used to treat all types of pain, but they do not treat inflammation. If a chronic condition causes pain, such as osteoarthritis, treating this with opioids will not change the inflammation that is occurring. The pain may be better with the opioids, but the disease is not being modified and one should expect to see inflammatory markers.

Chronic pain is defined as pain lasting longer than 3-6 months. Pain can be caused by any number of factors, and is a response to ongoing stimulation of pain receptors in the body. It is not very surprising that if we monitor blood borne markers, we can find elevations in those that are indicators of inflammation.

Osteoarthritis is a chronic degenerative joint disease. If it is painful, there is likely active destruction of tissue, and the joint may be warm and swollen. Osteoarthritis of the knees is very common, and we all know many older adults who complain of painful, swollen knees. Furthermore, the most common treatments are nonsteroidal anti-inflammatory drugs, like Motrin and Aleve.

Low back pain has many causes, such as:

Inflammation of nerves causing radiculopathy
Degeneration of the facet joints

First line treatments are meant to reduce inflammation. This is done sometimes by oral steroids, or long-acting steroid epidural injections. Steroids treat inflammation directly, and finding inflammatory markers when someone has low back pain is not surprising.

If a person has chronic pain, a good pain physician will recognize the causes of the condition. Treating the cause of pain with interventions that modify the disease is the best strategy. Treat the disease, and the disease markers will improve. Opioids are often a Band-Aid – they help in the short term but fail to address the underlying condition.

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