Extreme knee pain. My doctor says I should get counseling for depression and anxiety

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Sometimes we will see a patient who is reluctant to seek medical treatment for their chronic knee pain. The reason? “I have tried everything, nothing has helped. My MRI is not bad enough for me to get surgery and my doctor is recommending I get counseling. My doctor says my tests, my MRI, my examination, nothing warrants the amount of knee pain I am having.”

It is clear to see how a sense of hopelessness and depression can impact this patient’s ability not only to heal but to even understand if they can ever heal their knee pain. In our clinic, we see a lot of difficult knee cases. The first thing that we want to convey to patients is that for most people, we can help a lot. The first step towards healing is to help people understand their pain, what is causing their pain, and how we can help their pain.

Here is a summary of the topics we will be covering in this article.

Article summary

• People in pain have a heightened sense of pain – maybe your knee does hurt more than the MRI says it should.
• There really is something wrong in your knee and your brain agrees, you do have more pain than you should.
• Why does your knee hurt more than it should? See if this makes sense. The SOS of a sinking knee.
• Low-grade and chronic knee inflammation – has this changed your brain?
• “Doctors are not in tune” Researchers suggest understanding the pain issue is better than being dismissive.
• The impact of uncured knee pain: Depression.
• The researchers identified the 5 key factors that would influence successful or non-successful treatment outcomes in patients with knee osteoarthritis.
• What is one to make of this research? An optimistic outlook works for knee pain.
• How depression may make knee pain significantly worse than it should be. How patients with a terrible MRI had less pain, and patients with “better” MRIs had more pain.

People in pain have a heightened sense of pain – maybe your knee does hurt more than the MRI says it should

Do people with chronic pain suffer from more pain than they should?

Let’s look at a study of 30 patients with knee osteoarthritis and how doctors wanted to know what these patient’s pain threshold was. Because according to the initial observations, these 30 people should not have had as much knee pain as they said they had.

In this February 2019 study published in the journal Physiotherapy Theory and Practice (1) doctors compared 30 patients with knee osteoarthritis with 30 people without knee osteoarthritis in order to test pain thresholds in knee osteoarthritis patients. Measuring the study participants’ reaction to a pain stimulus, the researchers found that pain thresholds differed significantly between the two groups. The conclusion that these researchers came up with indicated that the pain the knee osteoarthritis should not have hurt as much as it did, but it did.

Here is what they said:

• “Allodynia (heightened pain, see definition below) and hyperalgesia (heightened pain, see definition below) were demonstrated in the knee osteoarthritis group, suggesting central sensitization (disrupted nervous system that is not managing pain well) in patients with mild to moderate severity of joint damage. Correlation between mechanical hypersensitivity (joint disease and inflammation) and psychosocial factors seems to be small, despite its significance.”

There is a lot to go over here and we hope that it will make sense to you and provide a path of understanding and more hopefully a path of healing.

• Allodynia is central pain sensitization, your nerves are not acting as they should in the pain response. It is making you feel more pain.  Allodynia can occur following normally non-painful stimulation, like taking a few steps. Here is where Allodynia gets interesting. You can walk a few steps without pain, yet the more your walk, the more pain starts developing to the point where you have much more pain than the walking should have caused. What happened? Let’s use an example that we have used in other articles, namely, your hip hurts worse than your MRI is saying it should and your doctor doesn’t believe you.

There really is something wrong in your knee and your brain agrees, you do have more pain than you MRI reveals. For many people, it is not in your head, it is in your knees.

Pain sensitization: This can be described as an oversensitive or overly aware nervous system. When damage in the knee occurs, the nervous system sends out signals for inflammation to occur. Inflammation is how the body heals. It is over inflammation that leads to chronic problems. The nervous system therefore sends message to start and stop inflammation based on pain signals and other factors. If this signaling system is off you get an MRI that shows knee damage but not the actual pain signals and the amount of pain the patient is actually suffering from.

We are going to present the evidence that for many people, the problem is not one created in their head. It is one created in their knee and their knee is sending urgent messages to the brain that something is wrong more than an MRI can reveal. In January 2022, European researchers writing in the medical journal Cartilage (2) found that pain sensitization has a high prevalence in knee osteoarthritis, “representing a relevant component of symptoms suffered by many patients.” In other words, it is real and affects many people.

The researchers concluded: “Pain sensitization should not be overlooked when managing knee osteoarthritis and its presence should always be considered to properly address this burdening condition.” Further, they write: “According to the results of this meta-analysis, up to one-fifth of patients with knee osteoarthritis presents an altered pain processing mechanism that, if disregarded, may lead to treatment failure and patient dissatisfaction. Indeed, several studies have shown that the presence of a “neuropathic” component of pain in musculoskeletal diseases may lead to an increased risk of pain chronicity and to worse outcomes after treatment.”

The key points:

• One in 5 knee osteoarthritis patients show an altered processing mechanism.
• several studies have shown that the presence of a “neuropathic” component of pain in musculoskeletal diseases may lead to an increased risk of chronic pain  and worse outcomes even after knee replacement.

Why does your knee hurt more than it should? See if this makes sense. The SOS of a sinking knee.

• Allodynia is an over-sensitization to pain. Your nervous system is overriding normal commands to get out pain messages.
• Hyperalgesia – “hyper pain,” can be induced by Non-Steroid Anti-Inflammatory Medications please see our article When NSAIDs make the pain worse. Hyperalgesia can be induced by pain medications, please see our article How narcotic pain medications can increase chronic pain. You have a lot of pain and the pain medication is making it worse.

Let’s look at the diagnosis of allodynia and Hyperalgesia and what may cause them.

Above we discussed pain signaling. Pain signaling are the messages the nervous system sends to the immune system to heal an injury. Pain also tells the brain that something is hurt and it needs rest. So let’s look at a problem created if pain signaling is off.

Let’s pretend that sinking ship is your knee. The knee ship recognizing it is sinking sends out SOS’s and emergency notifications looking for help. As the knee ship continues to sink, it starts to send more panicked and urgent SOS messages to the brain in an attempt to get the brain to send help to prevent the ship from sinking or the knee from collapsing. What type of help? The knee is asking for more inflammation, swelling, to keep the knee stable (or afloat).

For people with chronic knee pain, a familiar description of their pain is that after a few minutes of walking or standing, knee pain becomes extreme. Let’s put this into daily life. You have chronic knee pain. Your knee and brain are very aware that your knee is damaged and that if you do something that causes pain, the knee and brain will send extreme pain signals to stop. Make sense?

Does this scenario present a realistic explanation of one possible means to why you have more pain than you should?

• Your knee is frightened that you are going to hurt it. It is crying out by sending heighten pain messages to stop your activity. The pain is so severe you are taking medications that are making the pain worse.
• You go to the doctor in severe pain and the doctor says to you, “I don’t see it,” and may prescribe more pain medications, which will make it worse, or suggest you get counseling because your knee pain does not make sense to him/her. Here is where your doctor may suggest counselling.

Low-grade and chronic knee inflammation – has this changed your brain?

This fear of a sinking ship of the knee or pain catastrophizing, has it changed your brain to always fear pain and thereby make the pain worse? The answer according to research is yes, your knee is changing the way your brain thinks.

Let’s look at a paper published in December 2022 in the International journal of molecular sciences (3). The connection the researchers in this study are making is that chronic, long-term, low grade inflammation is a common factor in osteoarthritis and neuropsychiatric disorders. These disorders would include pain catastrophizing, heighten “unrealistic” sense of pain, anxiety, depression and eventual dementia. The researchers noted that “Lately, neuropsychiatric sequelae (mood disorders) of the disease have gained recognition. However, a link between the peripheral inflammatory process of osteoarthritis and the development of neuropsychiatric pathology is not completely understood.”

This is a continuation of our discussion from above. There is a connection between heighten pain and mood disorders, but it is unclear what it is. In this paper the focus is on inflammation. What the doctors of this study did was to explore “the development of neuropsychiatric disease in the presence of chronic peripheral low-grade inflammation with a focus on its signaling to the brain.”  Is the long-term inflammation changing your brain? Let’s remember low-grade inflammation may not look like a lot on an MRI. This may be why your symptoms are being described as “all in your head.”

The researchers describe the pro-inflammatory environment in the osteoarthritis-affected joint and the inflammation-signaling pathways that link the affected joint to the central nervous system as we will below. Using this and other research we can see a “cross talk” where your knee is telling your brain “Its worse than you think.”

The impact of uncured knee pain: Depression

There is a lot of research being published on the effects of depression on knee pain. In much of the research, investigators say that doctors are not in tune with these problems in their patients and their scoring systems for documenting depression may not be accurate. The one common thread that appears in many of the studies is that the knee pain patient suffering from depression needs to be offered treatments that give them hope and have a good personal support system. In our opinion, they need to be believed.

A 2016 study led by the University of Southern California (4) looked further into behavioral modification in knee and hip osteoarthritis patients with depression. In the very simplest terms, behavioral modification in patients with depression is training in how to replace pessimistic/catastrophizing thoughts, with thoughts that are more optimistic.

• The goal of this research was to see:
  • which osteoarthritis patients would benefit from behavioral modification and
  • those who would not benefit as much and
  • to identify these patients so they could be helped.

The researchers noted that based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified as targets for potential moderators.

Trial outcome variables (the factors that would influence all the patients regardless of age or weight, for example, included pain, fatigue, self-efficacy (a belief in one’s own ability to succeed), quality of life, catastrophizing, and use of pain medication.

The researchers identified the 5 key factors that would influence successful or non-successful treatment outcomes in patients with knee osteoarthritis:

1. The ability to cope with pain
2. The patient expectation for treatment response
3. Radiographically assessed disease severity, how bad the patient’s joint damage was
4. Age
5. Education.

Surprisingly they found that levels of depression at baseline were not associated with treatment response. So if a patient had less severe depression or more severe depression, their test outcome would be the same.

• Patients with interpersonal problems (lack of family support or poor marital or relationship status) associated with pain coping did not benefit much from the treatment.
• Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited.
• Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. (Our note: The worse the osteoarthritis was, the better the patient responded. Read into this what you will, but this is another example of an MRI showing severity of the disease that did not affect the patient’s positive response. In other words – the MRI is saying the patient should be much worse than they are).

What is one to make of this research? Optimistic outlook works for knee pain

• Patients with osteoarthritis and depression need strong family support, if not available, the patient needs to be optimistic about their own ability to have successful treatment. This can be difficult for some.
• Patients who are told of the severity of his/her knee or hip osteoarthritis based on their MRI should instead believe what their own body is telling them. In most cases, the MRI is saying they are worse than they really feel.
• If treatment is begun with optimism, and optimistic thoughts outweigh pessimistic thoughts, the greater the chance for the alleviation of symptoms.

How depression may make knee pain significantly worse than it should be. How patients with a terrible MRI had less pain, and patients with “better” MRIs had more pain

Let’s go further into the complex MRI discussion.

Doctors from the Benha University School of Medicine in Egypt wrote in the European Journal of Rheumatology (5) about how depression may make knee pain significantly worse than it should be, at least significantly worse than an MRI suggests.

In the research we cited above, the MRI suggested that the patient’s pain should be worse, in this research the MRI is suggesting that the patient’s pain should be less. The patients in the above study had worse MRIs and less pain, the patients as we will see in this study, had “better” MRIs and more pain. This is, of course, the inherent problem of MRIs: they do not always tell the true story.

These are the learning points from the Egyptian research:

• “Knee osteoarthritis can lead to psychosocial deterioration in addition to physical inability, which makes it difficult to interpret the source of the patients’ complaints. It is becoming increasingly evident that structural changes alone do not account for all musculoskeletal pain.”
  • In other words, depression makes the knee diagnosis much more challenging.
• The Egyptian doctors say this is especially true in cases of Baker’s cysts, osteophytes (bone spurs), and high Body Mass Index (overweight/obesity) which have a great impact on the pain and disability associated with osteoarthritis. Depression might be the culprit behind the discrepancy between MRI or ultrasound findings and the patients’ clinical scores.

At the University of Maryland, doctors examined depressive symptoms clearly associated with increases in pain and functional limitations in knee osteoarthritis patients. Publishing in the journal Clinical Rheumatology, (6) this research construct was to determine if depression severity accelerated problems of knee osteoarthritis and document it by radiographic and clinical assessments. They could not find evidence that depressive symptoms have a detectable effect on changes in radiographic disease severity in knee osteoarthritis. 

Are doctors asking knee pain patients the right questions to get the best determination of the patient’s depression challenges?

Writing in the medical journal Disability and Rehabilitation, (7) researchers in the United Kingdom are suggesting that people with chronic knee pain and hip osteoarthritis may benefit from “Acceptance commitment therapy,” a form of psychotherapy and behavioral modification. They hope this treatment would be especially hopeful in people who have significant pain. Such as those in the above study whose MRIs suggested that they should not have the severe pain they are suffering from.

As a side note, the researchers also questioned whether accepted depression and physiological scoring systems, such as the Rasch-transformed and standard scales were accurate in assessing these patients. In other words, were doctors asking patients the right questions to get the best determination of the patient’s depressive challenges?

In another study, the same group of researchers writing in the medical journal Disability and Rehabilitation (8) examined the type of questionnaires that should be offered to patients with knee osteoarthritis to determine levels of hopelessness and depression.

Here is what they wrote:

• “These findings indicate that questionnaires need to be checked for their ability to measure psychological constructs in the clinical groups to which they will be applied.”
  • For people with osteoarthritis, the state-trait anxiety inventory is an acceptable measure of anxiety
    • The state-trait anxiety inventory measures acute worry (STATE is transient anxiety, one that will go away. TRAIT is chronic anxiety, “worrying too much,” about something that does not need that level of worry, catastrophizing thoughts).
  • The revised FATIGUE SEVERITY SCALE is an acceptable measure of fatigue with the removal of items 1 and 2.
    • 1. My motivation is lower when I am fatigued. (Question should be removed as not helpful)
    • 2. Exercise brings on my fatigue. (Question should be removed as not helpful)
    • 3. I am easily fatigued.
    • 4. Fatigue interferes with my physical functioning.
    • 5. Fatigue causes frequent problems for me.
    • 6. My fatigue prevents sustained physical functioning.
    • 7. Fatigue interferes with carrying out certain duties and responsibilities.
    • 8. Fatigue is among my most disabling symptoms.
    • 9. Fatigue interferes with my work, family, or social life.
  • the Beck Depression Inventory seeks to come up with a cumulative scoring system to determine
    • Score 0–13: minimal depression
    • Score 14–19: mild depression
    • Score 20–28: moderate depression
    • Score 29–63: severe depression.
    • The researchers did not find this scoring system helpful to patients with knee osteoarthritis.
• The feeling of helplessness can be measured using the arthritis helplessness index. This index asked patients to rate the following statements by 1 strongly disagreeing, 2 disagreeing, 3 agreeing, or 4 strongly agreeing. Here is an example of the questions:
  • My arthritis is controlling my life
  • Managing my arthritis is largely my own responsibility.
  • I can reduce my arthritis pain by staying calm and relaxed.
  • When I manage my personal life well my arthritis does not flare up as much.
  • I have a considerable ability to control my arthritis pain.
  • No matter what I do, or how hard I try, I just can’t seem to get relief from my arthritis pain.

The combined impact of obesity and depression

A January 2023 paper published in the journal BMC Musculoskeletal Disorders (9) writes that “while many studies have reported the individual effects of both obesity and depression on osteoarthritis including increased joint pain and disability and increased radiographic degeneration, few studies have assessed their combined impact.” The researchers did not one study published in the medical journal Cartilage (10) which reported that “patients with obesity and comorbid depression have increased biomarkers of cartilage degradation and bony remodeling as well as worse pain and function over two years compared to non-obese individuals and individuals without depression.” In their own findings, the researchers say they are in agreement with, and complementary to, the results reported by that study with both studies reporting increased knee pain in participants with obesity and depression, and further their study demonstrates increased joint space narrowing in a subset of participants (women with low-grade knee osteoarthritis) over 4 years. Collectively, these studies suggest that individuals with comorbid obesity and depressive symptoms have greater progression of symptomatic osteoarthritis compared to what would be expected based on their individual effects.

In this video, Danielle R. Steilen-Matias, MMS, PA-C, of Caring Medical demonstrates how we treat a patient with a primary complaint of knee osteoarthritis.

• The person in this video is being treated for knee osteoarthritis as the primary complaint. The treatment takes a few minutes. The person in this video is not sedated and tolerates the treatment very well. For some patients, we do provide IV or oral medications to lessen treatment anxiety and pain.
• The first injection is given to the knee joint. The Prolotherapy solution is given here to stimulate repair of the knee cartilage, meniscal tissue, and the ACL as well.
• The injections continue over the medial joint line making sure that all the tendons and ligaments such as the medial collateral ligament are treated.
• This patient reported the greatest amount of pain along the medial joint line. This is why a greater concentration of injections is given here.
• The injections continue on the lateral side of the knee, treating the lateral joint line, and all the tendon and ligament attachments there, such as the LCL (lateral collateral ligament).

“No matter what I do, or how hard I try, I just can’t seem to get relief from my arthritis pain.” I have never heard of Prolotherapy

In the above studies from 2016-2019, doctors tried to come up with plans to treat symptoms of knee pain: depression.

In 2009, our team published in the Journal of Prolotherapy our findings on healing knee pain. This is what we wrote:

• This observational study was the first to show Prolotherapy helps not only the physical components of unresolved knee complaints such as pain, stiffness, range of motion, and crunching sensations, but also helps numerous quality of life functions including walking ability, sleep, athletic ability, activities of daily living, and feelings of depression and anxiety.
• This study also showed that 15 months after their last Prolotherapy session, the vast majority of improvements continued.
• In this study population, Prolotherapy reduced the patients’ subjective overall disability, medication usage, other pain therapy treatments needed, as well as depressed and anxious feelings.
• Prolotherapy improved the patients’ walking and exercise ability, sleep, activities of daily living, and work situation. For the vast majority of the patients, Prolotherapy had a long-lasting effect and changed their lives for the better.

What is Prolotherapy?

Prolotherapy is a regenerative medicine injection treatment that relies on simple dextrose to stimulate your immune system to start repairing your knee. In the above scenario, we described how a knee sends frantic messages to the brain to increase inflammation. Why does the knee do that? Why is it asking the brain for inflammation? Because inflammation is the healing response. Chronic inflammation, inflammation that does not shut off because the knee cannot heal itself, is the degenerative response.

Prolotherapy, in research, has been shown to initiate the positive inflammatory response while shutting down the negative and chronic inflammatory response. How? This is the subject for a much longer article that you can continue on with: The evidence for Prolotherapy Injections for knee osteoarthritis

Do you have questions about your knee pain? You can get help and information from our Caring Medical staff.

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References

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This article was updated May 8, 2023

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