Arthritic Knee Pain- It’s Not Always An Easy Fix
by Steve A. Mora, MD
Orange County Orthopedic Knee Specialist
I see patients with arthritic or degenerative knee pain on a daily basis. Trying to figure out the cause of knee pain is a personal challenge. I have a special interest in helping folks with arthritic knee pain. One of the reasons why I am passionate about keeping up with current research regarding arthritis is that I personally have knee pain secondary to a childhood injury. Both my knee were severely injured after I was struck by a bus In Peru (click here to learn more about my accident). I had to have numerous surgeries that helped but I still suffer from post traumatic arthritis and stiffness. Some of the procedures I have personally had include a distal femoral osteotomy, femoral lengthening, tibial tubercle osteotomy, osteomyelitis treatment, infection debridements, hardware removals and arthroscopy. My knee is extremely arthritic however I follow the same recommendations that I give patients. I know what works and what doesn’t. I also stay abreast on current treatments and knowledge.
Through my own experience I have figured out what helps and what does not. This reality has helped me become a better doctor and has helped me treat patients better.
There is a tremendous sense of gratification when I am able to diagnose the problem that is causing pain and then provide successful treatment. This is especially true when I see patients for a second opinion or patients who have already had surgery. Figuring out what is causing knee pain can be very challenging. Sometimes patients have more than one reason to have pain and other times the problem is not obvious. Sometimes the problem seems more confusing after having a ‘normal” MRI or Xray. Sometimes they have already had surgery for a meniscus tear but they continue to hurt. Usually the ideal treatment requires a multi-modality approach. That essentially means that there is not a single treatment solution but rather multiple small incremental changes that can lead to improved pain and function.
Therefore treatment of knee pain is not always straightforward. These are some of my considerations when I see patients with knee pain.
Take home message #1-Has the correct diagnosis been made for your knee pain? Has traditional treatment been optimized?
Take home message #2- Many patients do not know that arthritis, a.k.a. Degenerative joint disease and OA, causes numerous pathological changes within the knee joint and leg. Cartilage degeneration and thinning is at the heart of the problem, however, there is associated inflammation of the lining and fluid, tightness of the surrounding soft tissue, deformity of the leg (bowing), weakness of muscles secondary to disuse, stiffness of the joint, degenerative meniscus tears, loose bodies and bone edema due to joint overload. In order to treat your knee pain all these problems must be looked at and addressed.
Prior to making recommendations I first do a comprehensive evaluation of the knee. This includes a detailed history, physical exam, X-rays and often times a good MRI. This process starts with listening to the patient and asking very specific questions. The answers to those questions serve as clues that will help me determine what is causing the pain and how it’s affecting the patient’s life. The Xrays are also very important. I cannot do a proper evaluation with poor copies or the wrong views. The best view for looking at arthritis is the Bilateral Standing Weight Bearing PA view, lateral and sunrise. The MRI is also very important. It is used not only to look for meniscus tears but also for bone edema and loose chondral flaps.
Specific problems I see in patients with knee arthritis and how they are addressed:
–If I discover subtle loss of motion, especially loss of knee extension, tightness of the IT Band or loss of patella mobility, I address these issues with a home exercise program and physical therapy focusing on static stretching. The physical therapist is always given direction so that the patient’s time is not wasted.
–If there are mechanical problems such as chondral flaps, meniscus tear fragments or loose bodies they are addressed with arthroscopy.
–Some patients have severe inflammation of the joint which requires a Celestone steroid injection and/or a holistic anti inflammatory such as Traumeel. I will also recommend injecting Hyauluronate which is a gelatinous substance which helps to reduce inflammation and improve the characteristics of the joint fluid and remaining cartilage. For patients who prefer not to have a steroid injected into their knee I offer them a cocktail consisting of Toradol plus Traumeel. All of these injectable options can help.
–Patients with narrowing of the joint and significant bowing of the leg are recommended an unloading knee brace for walking. In appropriate situations I also recommend a simple yet effective wedge shoe orthotic which patients can get on line at http://www.drlannysinsoles.com/
–Overweight patients are recommended to seek help with nutrition and exercise. I will recommend that they see a physician who can evaluate them for endocrine issues that might be affecting their weight. I will encourage exercise such as simple walking or stationary bike. Hiking poles, a brace, and good shoes are always highly recommended.
–Knee arthroscopy is recommended for patients with loose meniscus fragments and chondral flaps who have catching and weight bearing related pain. At the time of surgery I shave loose and or inflamed tissue, release tight structures, and sometimes do abrasion chondroplasty. Abrasion or microfracture chondroplasty is done to promote coverage of the bare bone with a lining called repair cartilage. In these cases I make sure the patient uses crutches for 6-8 weeks after surgery.
–In many cases the bone under the arthritic surface becomes swollen. This finding is called a “bone marrow lesion”. This is often seen on MRI and on exam. Bone has nerve endings therefore bone that is stressed due to overload causes pain. Bone marrow edema is often times associated with extruded degenerative meniscus tears seen on MRI. Patients will complain of severe pain and tenderness on the inner side of the shin bone. If these patients end up requiring arthroscopy I will also do a simple procedure called Subchondroplasty which essentially reinforces the bone under the arthritis with bone cement (subchondroplasty info)
The last take home message: Once all of the pathological problems associated with arthritis are addressed and corrected and if a patient continues to have arthritis related knee pain, other treatment can be considered including platelet Rich Plasma (PRP), adult stem cell injections, unloading osteotomies, partial or total knee replacement.
I hope this information was helpful. Please let me know if I can be of service to you, your friends, or your family.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he finished in the top of his class with AOA Medical Society honors. He completed his Orthopedic Surgery training USC. He completed an extra year of training with a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County. Dr. Mora’s practice focus is on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Dr. Mora performs Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, ACL reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
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Restore Orthopedics and Spine Center
112o W. La Veta Ave, Third Floor
Orange, CA 92868
Office: (714) 598-1745
Fax: (714) 941-9539