Chronic knee pain troubles a significant number of people worldwide. It is a common problem amongst the aging population, and can indeed be very painful and debilitating, sometime even confining individuals to the bed. The most common cause of knee pain in elderly is osteoarthritis (OA), a condition where the cartilages of the knee joint have worn out due to wear and tear. This results in friction between the bones of the joint during movement which results in pain. The impact is more in overweight and obese because of the extra load on the knees. The risk of knee OA in overweight women is nearly 4 times and in overweight men is 5 times greater. It is not just the mechanical factors which promote OA in obesity but also the co-existence of disordered glucose and lipid metabolism and the highly metabolic and inflammatory environments have a significant role.

What can be done for chronic knee pain?

Initial management involves lifestyle modification, supplements, simple pain killers and physiotherapy. It is estimated that an extra Kg of weight exerts a force of nearly three to six times across the knee while walking. Thus, weight loss is an important modifiable factor in the treatment of knee OA which the affected individual can drive. Various studies have demonstrated that weight loss improves both pain and function in obese subjects with knee OA.

Local injections are considered depending on the severity of problem and other factors such as age, functional status etc. When the pain and discomfort is severe your doctor may offer you the option of undergoing a knee replacement surgery. This involves removal of the worn out part of joint, shaping the ends of the bone and placing a metal implant. This reconstruction of the knee joint allows for smooth, pain free movement for most individuals. However some, even following the rehabilitation process, continue to experience pain.

For those who are

• Not keen on the replacement surgery or
• Not fit to have one or
• Continue to have pain after knee replacement surgery

Cooled Radiofrequency is an alternative treatment. Details about this treatment can be found in the Knee pain section of the website and in old blogs.

What causes continued pain following surgery?

The causes of knee pain following replacement surgery can be located inside the joint (intra articular causes) or outside the joint (extra articular causes).

The intra articular causes include:

• Knee joint instability
• Loosening of the implant
• Infection of the bone or the joint space
• Problems related to the kneecap (patella)
• Osteolysis (loss of bone)
• Issues related to size or type of implant

It is important to rule out the extra articular causes when a patient complains of persistent knee joint pain following surgery, because they can have serious consequences if they are missed.

The extra articular causes include:

• Localized knee problems such as tendinitis and bursitis
• Pain radiating from the nearby joints/body parts such as spine, hip and ankles
• People who have ongoing psychological illnesses will also tend to experience longer postoperative pain
• Nerve injuries/ problems

The focus of a recent research in Oxford, UK has been weather the knee replacement should be done earlier and not as a last resort. The authors suspected that long term persisting knee pain can lead to changes in the nervous system (nerves, spinal cord and brain) which can be responsible for persisting pain even if the original cause is corrected.

Diagnosing the problem:

You doctor will go through multiple steps in order to evaluate the pain you are experiencing. This process includes, taking a detailed history of the pain, such as when what type of pain you are experiencing and when you experience it the most. Then your doctor will go on to examine the knee, which will help him/her to further narrow down on probable causes & identify problems such as stiffness, swelling, and issues with alignment of the joint.

You will be asked to undergo investigations such as, X-ray, MRI, blood tests including inflammatory markers such as CRP and ESR etc.

How to manage this condition?

Depending on the cause of your pain, you doctor may suggest a variety of treatment plans. On some occasions pain relief medication may help to control the pain, and even get rid of it completely. Physiotherapy is another option which has proven to be effective in managing pain following knee replacement surgery. Nerve blocks are sometimes offered if nerves are suspected to be the pain generator. Cooled Radiofrequency of the nerve supplying the knee can help in reducing or resolving your pain issues. Sometimes repeat surgery such as revision knee replacement is required If.

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• Not keen on surgery or
• Not fit for surgery due to other medical problems or
• Have persisting pain after knee replacement.

This procedure can also be used for sacroiliac joint pain as in patients with ankylosing spondylitis and for low back pain secondary to facet joint arthritis. It is a day care procedure performed under local anaesthesia with no requirement for hospital stay or prolonged rehabilitation. Normal activities can generally be resumed soon after the procedure with little or no recovery time. Less pain can lead to improved functionality and reduced medication requirements.

Knee joint is supplied by branches from many nerves and these are collectively addressed as genicular nerves. The initial diagnostic procedure involves local anaesthetic injections close to the nerves supplying the knee joint. If the diagnostic procedure produces good pain relief then it is beneficial to proceed with radiofrequency treatment from pain specialist. Radiofrequency treatment aims to reduce the pain signals being transmitted by the nerves to the brain. This is achieved by heating up a small area of the nerve using the electric current produced by radio waves. The procedure involves placing needles close to these nerves under x ray or ultrasound guidance followed by heating of nerves. Cooled differs from conventional Radiofrequency as it has water circulating through the device, needle tip and can create a larger treatment area increasing the chances of success. It can provide lasting pain relief for up to a period of 18- 24 months and has a low complication rate. I trained in this procedure in Germany a few years back and I use a combination of ultrasound and x rays to improve the chances of having a successful outcome.

Consult Best Pain Specialist In Delhi, Dr. Amod Manocha.

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