PHYSIATRIC APPROACH TO KNEE PAIN

Why Knee is important?The Knee is the largest human joint in terms of its volume and surface area of articulating cartilage. The Knee joint has the greatest susceptibility to injury, age-related wear and tear, inflammatory arthritis, and septic arthritisKnee pain accounts for approximately one third of musculoskeletal problems seen in primary care settings. 54 percent of athletes have some degree of Knee pain each year.

History

Mechanical symptoms Locking- Meniscal injury, Popping – Ligament injury, Giving way- DislocationJoint effusion

Timing:- Rapid – ACL / Bone #/ Gout , Slow- Meniscal /RA /OA Recurrence:- Meniscal injuryAmount:-Mechanism of injury:-

Characteristics of the patient's pain

Physical ExaminationInspection & Comparison of the knee

Palpation for point tenderness

Assessment of joint effusion

Range-of-motion testing

Evaluation of ligament and Meniscal integrity

Investigations

CBC ESRCRPRA FactorUric Acid

X-Ray - Standing AP view & Lateral

Causes of Knee Pain

• Tendinopathies• Bursitis • Chondromalacia• Meniscal Injuries• Cruciate Ligament Injuries• Medial & Lateral Collateral

Ligament Injuries• Osgood-Schlatter Disease• Iliotibial Band Syndrome• Osteochondritis Dissecans• Arthritis OA / RA

Tendinopathies

Palpate these points!

Palpate these points!

Palpate these points!

Tendinopathies

• Painful conditions in and around tendons in response to overuse

• Histo-pathology – Degeneration & disorganization of collagen fibres with no inflammation

• Matrix Metalloproteinases, tendon cell apoptosis, IGF 1, NOS

• Not much benefitted from NSAIDS

OA KNEES-Grading -0

OA grade I

Grade II

Grade- III

Grade IV

Physiatric Management of Knee Pain

• Physical Modalities• Orthotic• Viscous supplementation• Effusion – Ozone therapy• Proliferative injection therapy - Prolotherapy• Intra-Articular steroids• Pharmacotherapy• Weight reduction & Exercises

Physical Modalities

• TENS• IFT• US• SWD

Advanced Electrotherapy

Advantages

Different modes in one program

Long lasting

Sympathetic block

Dental to Cancer pains

Modality-Pulsed Magnetic Field

• High Energy Pulsed Magnetic Field- 400 to 700Gauss

• 20 to 30 mts.

• Chen CY, Chen CL, Hsu SC, et al. Effect of magnetic knee wrap on quadriceps strength in patients with symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2008;89:2258-2264

• Harlow T, Greaves C, White A, et al. Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee. BMJ. 2004;329:1450-1454.

• Nicolakis P, Kollmitzer J, Crevenna R, et al. Pulsed magnetic field therapy for osteoarthritis of the knee—a double-blind sham-controlled trial. Wien Klin Wochenschr. 2002;114:678-684.

• Segal NA, Toda Y, Huston J, et al. Two configurations of static magnetic fields for treating rheumatoid arthritis of the knee: double-blind clinical trial. Arch Phys Med Rehabil. 2001;82:1453-1460.

• Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994;21:1903-1911.

• Trock DH, Bollet AJ, Dyer RH Jr, et al. A double-blind trial of the clinical effects of pulsed electromagnetic fields in osteoarthritis. J Rheumatol. 1993;20:456-460.

Modality – LASER Therapy

• Mechanisms of action

• Photons – Energy –Repair• Fibroblast proliferation• Vasodilatation- Lymphatic drain• Blocking neuronal transmission• Endorphin secretion• Angiogenesis

PHOTOMECHANICAL EFFECT

   

Pressure waves stimulate the lymph draining system leading to dissolution of inflammatory mediators

PHOTOCHEMICAL EFFECT

Chemical homeostasis is restored.Leaking of inflammatory mediatorsis prevented leading to analgesia and repair of damaged tissues

PHOTOTHERMAL EFFECT 

Laser delivers photons providing energy for repair and promotes angiogenesis

Combination of different wavelengths

Laser Apparatus

LASER Application

•Efficacy of different therapy regimes of low-power laser in painful osteoarthritis of the knee: a double-blind and randomized-controlled trial.[Lasers Surg Med. 2003]• Laser acupuncture in knee osteoarthritis: a double-blind, randomized controlled study.[Photomed Laser Surg. 2007]•Low power laser treatment in patients with knee osteoarthritis.[Swiss Med Wkly. 2004]•Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis.[Orthopedic & Traumatol Rehabil. 2012]•Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials.[Lancet. 2009meta-analysis of randomised placebo or active-treatment controlled trials.

Efficacy of LASER Therapy

Thermogram before and after 8 sessions of LASER Therapy

Acupuncture

Orthotic management –Knee PainKNEE TRCTION

Knee Supports-Patella Stabilizing

Knee supports-Varus- valgus Preventing

Knee Supports Varus-Valgus correcting

Valgus deformity -Left

Foot-wear Modifications-Lateral or Medial wedges

Viscous supplementationHyaluronate sodium

Management of EffusionOZONE THERAPY

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OZONE THERAPY

Intra Articular Knee injectionsResistant Effusion, Repeated aspirationsMono-articularRheumatoid Arthritis & OA with effusionBaker’s cyst

30 micr/ml 4cc + 2ml 2% Xylocaine

Repeated 3 to 4 weeks X 5

Ozone- Anti-Bacterial, Anti-Fungal & Virucidal

Proteins in the effusion breaks down – Dehydration

Blocks Phosphodiasterase –A2 – Analgesic & Anti- Inflammatory

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Ozone Generator

Collecting Ozone directly into the syringe

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Mixing Ozone with 2% Xylocaine

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Injecting Ozone

Proliferative Inj. TherapyPROLOTHERAPY

• 25% Dextrose

• Fibroblast proliferation – Strengthening of ligaments – increases stability of Knee joint in OA.

• Regenerate damaged meniscii.• Repair ligament injuries

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Prolotherapy-Knee

• Medial & Lateral Collateral Ligament Injuries.• Meniscal tears• ACL-Partial tear• Osteo-Arthritis• Bursitis• Tendonitis• Jumper’s Knee• Osgood Sh. Disease

Hyper mobility & OA Knees

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Prolotherapy sites Knee

Prolotherapy sites Knee

Prolotherapy sites Knee

Knee prolo video

• http://youtu.be/nYeMAIv8bbY

Steroids VS Prolotherapy

STEROIDS• Anti-Inflammatory• Suppresses natural repair• Expensive & Painful inj.• Only small areas can be

treated• Can change Diabetic status• Degenerate tendon –

Rupture• Cartilage destruction-

Worsening of OA

PROLOTHERAPY• Controlled Inflammation• Enhances natural repair• Cheap, acceptable &

unique• Large areas and more

volume• No change in Glycaemic

status• Safe to give in tendon

insertions and joints

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Intra-Articular Steroids

• Depo-Medrol / Triamcinolone

• Indications- RA & Waiting for TKR

• Side effects – Cartilage damage

• Stigmatized

Chondroprotective agents• Glucosamine• Chondroitin• Diacerine• S-Adenosyl Methionine• Type II Collagen Peptide• Vit. D

• NSAIDS, Tramadol & Paracetamol

Management of Obesity

• Most useful single intervention

• Diet

• Sleeve Gastrectomy

Exercises

Non-weight bearing exercises

Cycling

Height Adjustment

Seat width

When to refer for Surgery!

• Major Meniscal Injury

• Complete ACL tear

• Stage III and IV OA knees

• Recurrent Patellar Dislocation

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