The knee is a complex joint consisting of bones, cartilage, ligaments, tendons and muscles that work together to ensure smooth stable joint motion, but at the same time, this also makes the knee potentially more susceptible to various kinds of injuries. Knee problems can develop if any of these structures are damaged by overuse or injures during sporting or other activities. These conditions may impair mobility as well as the quality of life of patients. All these conditions require appropriate treatment, which may be non-surgical or surgical, to restore function and return normal activities.
The non-surgical orthopaedic treatment options can be subdivided into non-pharmacological and pharmacological interventions. The goal is to provide symptomatic relief and improve the quality of life. These treatment options can also be considered as an adjunct after any surgical treatment.
Non-Pharmacological Intervention
Non-pharmacological interventions may range from simple lifestyle modification to more formal physical exercises and rehabilitation programmes.
Some of the non-pharmacological interventions include:
- Weight reduction and physical exercise - The lifestyle changes resulting in weight loss in obese individuals and doing appropriate physical exercises is important role in prevention and management of the knee conditions. The optimal weight (BMI) should be 18.5 to 25. BMI of 25-29 is considered over weight and a BMI over 30 is considered as obese. Exercises may need to be modified in people suffering from cardiovascular diseases. Intense exercises are not ideal for all patients and every programme must be individualized and supervised.
- Transcutaneous electrical nerve stimulation (TENS) – The transcutaneous electrical nerve stimulation method involves the use of low-voltage electric impulses to relieve the pain. It is thought to provide pain relief by inhibiting the conduction of pain impulses to reach the receptors in the brain and spinal cord. The patient wears a device that generates the impulses that offer pain relief to the patient. Frequency of the impulses, duration of treatment and location of the electrical electrodes on the body are decided by severity of condition as well the response. Using the device for a period of at least 4 weeks may provide better pain relief. Contraindications are patients with a pacemaker or cochlear implant, or those suffering from epilepsy. It should also not be used during pregnancy.
- Thermotherapy – Thermotherapy involves application of hot or cold packs to the affected area. There is some evidence to support the use of cold therapy in providing symptomatic relief. It is contraindicated in individuals with thermoregulatory impairments (e.g. Raynaud’s disease). Patients with peripheral vascular disease, diabetes, cardiovascular disease and hypertension, or who are pregnant should use it with caution.
- Acupuncture – This method involves insertion of sterile needles into specific acupuncture “pressure” points to restore the flow of “qi”, a form of energy and thereby relieves the pain. A modification in acupuncture is electro-acupuncture where the needles are stimulated by an electro-stimulator. Acupuncture performed by trained professionals is considered to be safe and offers pain relief. However, it may have certain risks if used by untrained professionals.
- Patellar taping – Patellar taping can be tried as a short-term treatment particularly when performing normal activities deteriorates the knee condition. The principle behind the treatment is stabilization of the knee joint by altering the distribution of stress and joint pressure. Any response depends on the strapping technique used and the time for which it is strapped.
- Massage therapy – It is one of the oldest methods of treatment and reduces pain by increasing the circulation of blood and lymph as well by reduction of muscle tension, but its main benefit may be due to the therapeutic effect of the touch.
Pharmacological Interventions
Pharmacological interventions include management of pain using medicinal preparations such as pain- relieving capsules or injections.
- Simple analgesics – Paracetamol taken regularly remains the most effective and non-addictive simple analgesic preparation utilised. In the pre-operative or chronic phases, this is most often prescribed as the slow release form (e.g. Panadol Osteo) taken 3 times daily.
- Non-steroidal anti-inflammatory drugs (NSAIDs) - These are effective in reducing pain and inflammation of the knee. Overdosing as they are known to cause hepatotoxicity, and patients with liver diseases will need to modify dosages. A number of side effects are reported particularly with the concomitant use of diuretics, angiotensin converting enzyme inhibitors, angiotensin 2 receptor blockers, anticoagulants or oral corticosteroids.
- Steroid Injections - Injections of steroids may be given directly into the affected joint for severe pain when use of oral NSAIDs does not bring much relief, particularly when the knee has significant swelling. Steroids potent anti-inflammatory drugs and if used orally may cause other generalised systemic side effects.
- Weak and strong opioids - Opioids are utilised when simple analgesic medications or NSAIDs do not provide symptomatic pain relief, if other treatments have intolerable side effects, or when surgery is delayed or contraindicated. Whilst they are clearly stringer in their pain relief effect than NSAID’s, they are known to cause side effects such as dry mouth, nausea, vomiting, dizziness and constipation. Overdose may lead to respiratory depression. The dose should be reduced slowly otherwise it can cause withdrawal effects. Opioids are also known for addiction and should be used short term under supervision.
- Disease modifying anti-rheumatic drugs and biological agents (DMARDs) – This group of drugs aim at halting the progression of disease and offer symptomatic relief. Biological agents are the antibodies against the disease causing agents manufactured using genetic engineering technology. These agents are recommended in individuals with severe disease conditions, particularly the inflammatory arthritis conditions, such as rheumatoid arthritis.
- Other treatments - Occasionally the use of braces and orthoses are recommended, as are trials of glucosamine and chondroitin sulphate, electromagnetic therapy, vitamin supplements, herbal and other dietary therapies. A number of these have interactions with other drugs and may need to be ceased if surgery is planned.
These therapeutic options should be discussed with A/Prof Woodgate before initiating the treatment, or if surgery is planned.