Dr. Anikar Chhabra
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Our Guest Columnist this month is Dr. Anikar Chhabra, an orthopedic surgeon currently practicing at The Orthopedic Clinic Association (TOCA).
Chronic knee pain is one of the most common orthopedic problems that presents to our clinic. There are several different factors that go into determining how these patients are treated. The first and possibly the most important is a thorough history of the problem. This gives the orthopedic surgeon the ability to determine how debilitating the pain is, how long the symptoms have been occurring, how severe the symptoms are, what type of activities aggravate or alleviate the pain, and what treatments have been used. With this information the physician can develop a working diagnosis.
A complete orthopedic exam of the knees is then performed. Important information such as range of motion, knee stability, swelling, and muscle strength are obtained. Certain special tests are performed to try to reproduce symptoms to better determine the source of the pain.
The third step is to obtain dianostic testing. X-rays, MRIs or CT scans may be utilized depending on your initial diagnosis.
With all this information in hand, a working diagnosis can be developed. Based on the x-rays and exam, the knee pain can be characterized as degenerative (or arthritic) or not degenerative. The treatment of an arthritic knee is very different from one that is not.
If the knee does not show signs of arthritis, some type of damage to the structures of the knee may be suspected. This can include meniscus tears, cartilage defects, or loose foreign bodies in the knee. The pain may also be coming from the muscles, tendons and ligaments surrounding the knee, and not necessarily from inside the knee. This can often be differentiated by swelling inside the knee. MRI is often indicated to determine intra-articular pathology in these cases.
Chronic knee pain due to arthritis is a progressive process. Arthritis, or wearing away the cartilage at the ends of the bone, cannot be reversed. Without this cushion, the knee doesn’t glide smoothly and can cause significant pain. Treatment for this pain is based on the severity of the symptoms and how advanced the arthritis is.
The first step in treating an arthritic knee is beginning a home exercise program and physical therapy to strengthen the supporting structures around the knee. This can help relieve symptoms by causing less stress across the knee joint. Also, if the patient is overweight, weight loss is strongly encouraged to decrease stress on the knees. Appropriate footwear can decrease pain, especially in cases of patellofemoral arthritis.
Often, an anti-inflammatory medication is prescribed as well. It is important for these patients to stay as active as possible and maintain good motion in the knee, as this has proven to decrease symptoms of arthritis. Often patients can get several years worth of relief from their symptoms with these non-invasive treatment modalities.
The next step, after the above treatments have become less effective, is to try to supplement the treatment with injections. Cortisone injections into the knee give a concentrated dose of anti-inflammatory medication into the knee. These shots can be given up to every three months if needed, but can cause both local and systemic side effects. As the arthritis progresses the effectiveness of the steroid injections decreases.
Recently, a new type of injection has been used for knee pain, called viscosupplementation. These “gel shots” are given in a series of injections, and have been shown to be effective in approximately 75% of patients. The series can be given every six months. Patients should continue to do home exercises and stay as active as possible during these treatments.
The final step when all of the above treatments have failed is to perform a total knee replacement. The time to do this is up to the patient, when they have “had it” with the pain and failed conservative treatment. It is a major surgery, however, and the results are life changing. Over 400,000 knee replacements are performed in the US every year. There are risks involved with the surgery that need to be discussed between the patient and the physician. Some patients are not candidates for joint replacement due to medical problems that put them at risk for surgery. These patients are treated with continued conservative treatment and other methods such as selective nerve blocks and pain management modalities.
Knee pain is a real issue, but with the right approach and treatment, many patients can get back to the active and healthy lifestyle they desire.
Dr. Chhabra is a national expert in the field of orthopedic surgery, knee surgery, and sports medicine. He is Board Certified in Orthopedic Surgery with Subspecialty Certification in Orthopedic Sports Medicine.
Dr. Chhabra specializes in arthroscopy of the knee and shoulder, minimally invasive surgery and sports-related injuries. He also treats complex disorders of the knee such as multiple ligament injuries, articular cartilage procedures, osteotomies, unicompartmental knee replacements, total knee replacments, and meniscal transplants. For an appointment with Dr. Chhabra, please call the Orthopedic Clinic Association (TOCA) at 602-277-6211.
