Knee Pain Treatments
Ross Hauser, M.D., Marion Hauser, M.S., R.D.
Over one million Americans annually have knee surgery. More than five hundred thousand of these will be arthroscopies and two hundred and fifty thousand will be total knee replacements. Most of these orthopedic surgeries will be done in an attempt to relieve the pain of a degenerated knee. How come there are so many degenerated knees?
The history in most folks, including elite athletes, is that they had a simple soft tissue injury, either a strain or a sprain. An injury to a tendon or muscle is called a strain, whereas an injury to a ligament is called a sprain. After the injury, the coach, athletic trainer, or physician prescribes the R.I.C.E. protocol. This includes rest, ice, compression, and elevation of the leg. Because the injury didn't heal, a nonsteroidal anti-inflammatory medicine is offerred, than a cortisone shot.
Many people get two or three of these. What most people don't realize is that to this point everything that was done promoted non-healing of the injury. You see all of these treatments are anti-inflammatories which inhibit the normal healing reaction of the body which is inflammatory.
Eventually the cartilage decays because of the above scenario and arthroscopy is done to "clean out" the joint. Generally by this time, the person can no longer run because of the pain, thus, no more sports. Given enough time-total knee replacement.
People reading this website are either looking for alternatives to help heal their injured knee or have already experienced the "knife treatment" (surgery) and still need their injured knee healed. The first step in healing an injured knee is to stimulate inflammation because inflammation is how the body heals. Any treatments given that decrease the normal inflammatory healing reaction will decrease the body's chances to heal the injured area.
Imagine a person strains their knee and starts having pain. In simplistic term the pain is a signal to the patient and the physician that something is weakened in the joint. To get rid of the pain the structure must be strengthened. In the list are five ligaments, two menisci, one articular cartilage, one group of tendons (pes anserinus) and only one muscle (quadriceps). The main difference between muscles and the rest of the structures is that muscles are massively strong structures with a tremendous blood supply, both outside and inside the muscle (this is why steak is red). Ligaments (representatives of all the rest of the structures), on the other hand, are small tissues that have a poor blood supply (why they appear white).
Muscles, because of their good circulation, heal quickly and rarely cause a long-term problem, whereas ligaments, due to their poor blood supply, often heal incompletely and are the cause of most chronic sports injuries and resultant chronic knee pain. The reason that most elite and recreational athletes give up their sports is because of nonhealing ligament injuries of the knee.
R.I.C.E.
The R.I.C.E. treatment is the gold standard for pain management and sports injuries today. Just go to any emergency room or sports trainer with an acute knee sprain or other joint injury, and the injured person will be given these instructions: Rest, Ice, Compression and Elevation. Most people would also receive instructions to take anti-inflammatory medications. This treatment is recommended because ligament sprains, that is, meniscal / articular cartilage injuries, are often accompanied by quite a bit of swelling, called edema. The premise with the R.I.C.E. treatment is that the swelling and edema is harmful to the tissue.
Understanding the difference between muscles and the rest of the structures around the knee is crucial to understanding why the R.I.C.E. treatment is totally inappropriate for healing ligaments, menisci, tendons, and articular cartilage injuries. Muscles, such as the quadriceps, occupy an entire thigh, and have the strength and power to allow some athletes, like weight lifters, to squat in excess of 800 pounds. Muscles are the structures that move the joints.
Contrast this to most ligaments, which are generally less than one inch in length, and whose width is measured in millimeters. These small structures have the job of binding the bones together. The menisci and articular likewise, have their widths measured in millimetes and have the important task of cushioning the joints, as in the knee.
Muscles have a tremendous arterial blood supply, that can increase 25-fold during strenuous exercise. Ligaments, articular cartilage, menisci, and many tendons have terrible blood supplies. The menisci and articular cartilage depend on the joint fluid for their nutrition. The ligaments normally receive blood vessels from small arterial plexuses from the joints, but they themselves have essentially no blood vessels. This implies that at least some degree of their nutrition must come from diffusion of nutrients, most likely from the joint itself. Much like the articular cartilage and menisci. The actual insertion sites of ligaments into bones, called the fibro-osseous junction, are also essentially avascular (without blood supply). It should be evident now why ligaments are so easily injured. A joint is jostled during an athletic event. The small blood vessels to the joint are sheared. The little blood supply that the ligaments had is then cut off. The body has to repair the damage, but how can it do so if no immune cells can get to the area because of the poor blood supply? The blood supply to the ligaments is the worst at the point where the ligament attaches to the bone, called the fibro-osseous junction. This is the weak link in the ligament-bone complex. This is the most common area injured in the athlete and is responsible for much of the chronic knee pain that people feel. This is the exact site where Prolotherapy is administered.
As a result of immobilization (rest), ice, compression, and elevation blood flow is decreased to the knee or joint where it is used, resulting in reduced immune cell production necessary to remove the debris from the injury site. This produces formation of weak ligament and tendon tissue. The ligament-bone interface is tremendously susceptible to the effects of immobility or disuse. For instance in one study, just nine weeks in plaster cast caused the medical collateral ligament to lose 39 percent of its strength due to bone resorption at the point where the ligament attaches to the bone. Although muscle weight returned to normal by around 12 weeks, bone remineralization was not complete at 24 weeks and ligament strength was still not normal at 30 weeks. This is another reason why you cannot treat muscle injuries the same way you treat ligament injuries. They are microscopically, anatomically, physiologically different than ligaments. Ligaments, like menisci and articular cartilage, are tremendously sensitive to the detrimental effects of rest, immobilization, ice, anti-inflammatories, and cortisone shots. For these reasons, athletes and others who want to heal must say "no" to these therapies.
Swelling after an injury is the physical manifestation of inflammation. Swelling is evidence that the body is working to heal itself. Use of ice (and the R.I.C.E. protocol) will obviously prevent the body from repairing the injury. It has been shown that as little as five minutes of icing a knee can decrease both blood flow to the soft tissues and skeletal metabolism. Icing an area for 25 minutes, which is what most people and athletic trainers do, decreases blood flow to the soft tissues and skeletal metabolism by 400 percent. Healing is thus hindered by a decrease in blood flow and metabolism to the area. Icing (and the R.I.C.E. protocol) increases the chance of incomplete healing by decreasing blood flow to the injured ligaments, tendons, menisci, and cartilage. This increases the chance of re-injury or the development of chronic pain.
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