My doctor says my knee should not hurt me as much as it does. It must be my head, I should get counseling

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

My knee hurts worse than my doctor believes it should

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 it, and how we can help.

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

Do people in pain suffer from more pain than they should?

A February 2019 study published in the journal Physiotherapy Theory and Practice (1) 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 had should not have hurt as much as it did, but it did.

Here is what they said:

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.

Your knee hurts worse than your MRI is saying it should

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

Let’s pretend that you are on that ship above. Let’s pretend that ship is your knee.

The ship has struck an iceberg. It is now damaged beyond its crew’s ability to repair it. The ship/knee needs help or it will sink.

Your knee is now sending panicked SOS messages to the brain in an attempt to get the brain to send help to prevent the ship from sinking. What type of help? Inflammation to create swelling to keep the knee stable (or afloat).

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

“Doctors are not in tune”


Researchers suggest understanding the pain issue is better than being dismissive

Is it any wonder why people with knee pain are depressed? They feel a pain that clinicians say should not be there. Remember what the researchers above said?

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 study led by the University of Southern California (2) 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 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 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.

What is one to make of this research? Optimism works

How depression may make knee pain significantly worse than it should be


How patients with a terrible MRI had less pain, and patients with a “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 (3) of 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 MRI 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:

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, (4) 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 patients the right questions to get the best determination of the patient’s depression challenges?

Writing in the medical journal Disability and Rehabilitation, (5) 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 (6) 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:

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

“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 treating a symptom 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:

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 shut 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.

1 Bevilaqua-Grossi D, Zanin M, Benedetti C, Florencio L, Oliveira A. Thermal and mechanical pain sensitization in patients with osteoarthritis of the knee. Physiotherapy theory and practice. 2019 Feb 1;35(2):139-47. [Google Scholar]
2 Broderick JE, Keefe FJ, Schneider S, Junghaenel DU, Bruckenthal P, Schwartz JE, Kaell AT, Caldwell DS, McKee D, Gould E.  Cognitive behavioral therapy for chronic pain is effective, but for whom?. Pain. 2016 Sep 1;157(9):2115-23. [Google Scholar]
3 El Monaem SM, Hashaad NI, Ibrahim NH. Correlations between ultrasonographic findings, clinical scores, and depression in patients with knee osteoarthritis. European Journal of Rheumatology. 2017 Sep;4(3):205. [Google Scholar]
4 Rathbun AM, Yau MS, Shardell M, Stuart EA, Hochberg MC. Depressive symptoms and structural disease progression in knee osteoarthritis: data from the Osteoarthritis Initiative. Clin Rheumatol. 2017 Jan;36(1):155-163. doi: 10.1007/s10067-016-3495-3. Epub 2016 Dec 12. [Google Scholar]
5 Clarke SP, Poulis N, Moreton BJ, Walsh DA, Lincoln NB. Evaluation of a group acceptance commitment therapy intervention for people with knee or hip osteoarthritis: a pilot randomized controlled trial. Disability and rehabilitation. 2017 Mar 27;39(7):663-70. [Google Scholar]
6 Lincoln N, Moreton B, Turner K, Walsh D. The measurement of psychological constructs in people with osteoarthritis of the knee: a psychometric evaluation. Disabil Rehabil. 2017 Feb;39(4):372-384. doi: 10.3109/09638288.2016.1146356. Epub 2016 Mar 17. [Google Scholar]

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