The different types of knee pain in menopausal and post menopausal women and non-surgical treatment options

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

In this article, we will explore the challenges menopausal and post-menopausal women face with knee pain and possible treatment options. Many women contact our office with knee pain challenges. They will tell us that they lead or have led an active lifestyle for decades. They also have a long history of sports participation and some have very physically demanding lines of work or jobs where they have to stand on their feet all day.

They also tell us about their knee pain and a somewhat lengthy medical history to include low back pain, hip pain, ankle, and foot pain as well. Some women report an acute injury, a torn meniscus while skiing for instance. Some have knee pain because part or all of their meniscus was removed following a sports-related injury decades ago. Some will tell us about an even more extensive arthroscopic knee surgery history and the recommendation to a new surgery because their knee gave out suddenly and is causing them a lot of pain. This “giving out” or “knee-buckling” event followed a routine activity they enjoyed, such as a simple jog, a mountain hike, pickleball or softball game, and of course tennis and the front knee collapse and pain of the golfer.

We also hear from the women with significant and severe post-traumatic osteoarthritis in their knees from ACL sports-related injuries that occurred many years and decades ago. Some women had the ACL Rupture, the ACL reconstruction, and then the ACL Revision surgery. Some women then repeated this with an ACL re-rupture two or three years after the original, soccer or lacrosse, or other sport-related ACL rupture. Many women who contact us are still in their early 40’s but tell us that they “walk like an old lady” and are plagued by swelling, limited or lost range of motion, and “bone on bone” knees. Further, some of these young women, in their 40’s are being prepped for total or partial knee replacement and are going down the checklist of Hyaluronic acid and cortisone injections and other conservative methods that will need to fail so knee replacement at a young age can be justified. For many, an exercise bike or cycling is the last activity they can perform, and while many can enjoy this activity, it is the other activity that they want to return to. They are not confident in the knee replacement and its ability to get them back to the sport.

This article is a companion piece to our article Hormone replacement therapy and degenerative joint disease. In this article we discuss:

• The controversies surrounding hormone levels and osteoarthritis.
• There is a connection between painkillers and hormone replacement therapy that makes the pain worse
• The role of estrogen in joint pain. Does estrogen deficiency make “bone on bone”?

Discussion topics in this article:

• Chronic knee swelling is developing and worsening knee osteoarthritis.
• A Meniscus tear from nowhere.
• The problem with opioids in menopausal and post-menopausal women.
• The different types of diagnosed knee pain in the menopausal, post-menopausal woman.
• Diagnosis of Iliotibial band syndrome – runner’s knee or jumper’s knee.
• Like many sports injuries, doctors tend to manage symptoms as opposed to fixing the problem of Iliotibial Band Syndrome.
• Diagnosis: Patellar Tendinopathy.
• Cortisone injection concerns.
• The main problem with patellar tendinopathy – is it a degenerative disorder rather than an inflammatory disorder – should you have surgery?
• Patellar taping.
• Non-surgical solutions to the problem of chronic and recurrent Patellar Tendinopathy.
• A quick word on Patellar Tendinopathy and ligament weakness.
• Other knee tendinopathies.
• Knee osteoarthritis Treatment guidelines – Exercise and physical therapy.
• Knee osteoarthritis Treatment guidelines – aquatic resistance training.
• Treatment guideline – Prolotherapy

Knee osteoarthritis – It started with a meniscus tear

Some women who contact our office will tell us that they were very active and had no knee pain or knee pain symptoms such as swelling. They were happy going about their business and sports and then one day they turned to the left or right with one of their legs planted and the next thing they knew they were getting an MRI because their doctor suggested some type of meniscus tear had occurred.  This is not really a meniscus tear from nowhere. It is the result of degenerative changes in the woman’s knee.

A study in 2008 looked at this phenomenon of a meniscus tear in healthy postmenopausal women. Published in the journal Osteoarthritis Cartilage (6) the researchers examined Fifty-seven post-menopausal women with no knee pain or knee problems. Then they followed these women for two years to see if they developed new or worsening meniscus tears and if cartilage loss had something to do with bone loss at the tibial plateau. The tibial plateau is that part of your shin bone that the femur of thigh bone meets at the knee. Remember these women had no knee pain and were asymptomatic, but did show some knee damage on an MRI.

Two years after the baseline MRI:

• Forty-six percent of women had a meniscal tear in either the medial and/or lateral compartment.
• Women who had a tear were older and had more lateral cartilage defects (your knees have developed instability, you are becoming knock-knee and the inside knee cartilage were taking the brunt of this new knee alignment pressure or you are becoming bow-legged and the medial or outside your knee cartilage was now trying to handle this new load).

What this study concluded was that “meniscal tears are common in asymptomatic postmenopausal women and that they become more common with age. Meniscal tears were also associated with greater tibial plateau bone area but not cartilage volume, providing support to the hypothesis that tibial plateau bone changes occur before significant pathological changes in cartilage.”

So what does this all mean to you? 

• Even if you have no knee pain or limping or swelling, your knee takes on postmenopausal changes caused by developing knee instability. Your knee is loosening up because of knee ligament laxity.
• These changes start to tear at the meniscus and cartilage
• It is not understood the cause of why bone would break down before the cartilage in this study but possible answers can be the hormonal decline, poor diet, or developing obesity or weight gain.

In other words, many factors can lead a seemly non-problematic knee to become problematic “out of the blue.”

Then I tore my meniscus again – What are we seeing in this image?

The knee in this MRI had prior meniscus surgery. Post-surgical changes in the meniscus are demonstrated because the meniscus is smaller than it should be. Part of the meniscus is missing. This MRI followed another post-surgical MRI which revealed similar meniscus damage. (MRIs after surgery are to confirm the success of the surgery or to look for reasons the patient continues to have). The problem for the radiologist is they he/she cannot tell if this person’s meniscus is still degenerating or the damage that is in the meniscus now is the surgical damage.

Meniscus injury and pathology. Past surgery and current surgical recommendation.

For many years there has been a controversy as to whether arthroscopic knee surgery should even be offered to middle-aged patients. Some patients may get into that situation where they have had numerous surgeries.

Here is a study that was in the August 2019 issue of The American Journal of Sports Medicine. (6)

Here are the learning points:

• There is controversy about the benefit of arthroscopic partial meniscectomy for degenerative tears and damage in middle-aged patients.
• The study wanted to determine outcome success in middle-aged patients with no or mild knee osteoarthritis who had either a degenerative meniscal tear or a traumatic tear.

Results: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild osteoarthritis. Predictors of dissatisfaction with arthroscopic partial meniscectomy were female sex, obesity, and lateral meniscal tears. These findings suggested that arthroscopic partial meniscectomy was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious osteoarthritis, and with failed prior physical therapy.

In other words, if you do not have degenerative arthritis developing, were not obese, had the meniscus tear on the outside, and were a man. This surgery would be more successful for you as a “medium-term option.” That is until your knee started to deteriorate further and you needed an “end-term option.” Knee replacement.

Let us point out again, many people have very successful arthroscopic partial meniscectomy procedures. These are the people that we do not see at our center. We see people with less than successful outcomes.

We carry on this discussion in our more extensive article Arthroscopic knee surgery when over 50. Are there non-surgical options?

For many women, it is more than simple knee pain.

Many women will go to the orthopedist or physical therapist and the sole focus of their treatment will be on the knee pain. A March 2018 study in the Public Library of Science One (7) suggested that doctors go beyond that. Here is what they wrote:

“Women without knee osteoarthritis tended to report increasing knee pain with increasing age. BMI (Body Mass Index – weight) is considered a significant controllable factor in knee pain in women regardless of the presence of radiographic knee osteoarthritis. The presence of depressive symptoms may aggravate knee pain in women with knee osteoarthritis. Attention needs to be focused on concomitant musculoskeletal problems such as lumbar spinal and hip diseases in women with knee pain.”

What these doctors are suggesting is what we look for in our patients. Do they have a supportive family, do they have hip and back pain as well. Treating a meniscus tear or some other abnormality as seen on MRI may not be sufficient in understanding knee pain in menopausal and post-menopausal women.

The problem with opioids

An October 2019 study in the Journal of General Internal Medicine (1) was published by doctors at the San Francisco VA Health Care System and the University of California, San Francisco. In this paper, these doctors examined the problem of opioid abuse in middle age women vets.

“Among midlife women Veterans with chronic pain, those with evidence of menopausal symptoms had increased odds of long-term opioids, high-dose long-term opioids, and long-term opioids co-prescribed with Central Nervous System depressants, independent of known demographic and clinical risk factors.” In other words, opioids are prescribed without clearly knowing the impact of these post-menopausal service veterans.

“Although rates of opioid use and opioid-related mortality have risen dramatically among midlife women over the past two decades, drivers of increased risk in this vulnerable population had not been previously identified.” In other words, prescriptions are being given and there is no clear reason why except pain management beliefs.

“These findings raise the possibility that menopausal symptoms are an under-recognized indicator of risk among midlife women with chronic pain, influencing treatment decisions that enhance the risk for opioid-related disability and mortality. Safe and effective comprehensive care for midlife women with chronic pain should include recognition of the potential role of menopause in pain experience and management and the possibility that pharmacological treatments for menopausal symptoms may inadvertently put women with chronic pain treated with long-term opioids at increased risk for opioid misuse and overdose.”

Comment: In middle-aged women, there can be types of prescriptions at play including those to help alleviate hormonal problems. It is not clear whether the combination of hormones and painkillers is causing more problems than they are helping. We address the complexity of this subject in our article: Hormone replacement therapy and degenerative joint disease.

Hormones and knee pain

In July 2017, researchers published in the journal Osteoarthritis and Cartilage (2) findings to suggest: “In women but not men, low serum levels of endogenous estradiol, progesterone and testosterone are associated with increased knee effusion-synovitis and possibly other osteoarthritis-related structural changes.”

The different types of diagnosed knee pain in the menopausal, post-menopausal woman

Many people who contact us have a very good understanding of what is going on in their knees beyond the umbrella term “knee pain.” In fact, the emails that we receive to our center are usually detailed and contain parts of an MRI report. This is generally an indication that this person has taken an active role in determining their knee pain treatments. It is equally indicative that they have taken a more active role out of frustration for lack of progress in getting help for their knee or a recommendation to a knee surgery that they do not want. Here are some of the more common diagnoses of knee pain and general thoughts.

Diagnosis of Iliotibial band syndrome – runner’s knee or jumper’s knee

We have a more extensive article on our website Iliotibial band friction syndrome – Sports-related knee pain. We are presenting a summary of that article here

Women who do a lot of running and have knee pain may have been told that they have a “runner’s knee.” If you are involved in a sport where you do a lot of jumping or lunging or upward motion as in “jumping jacks you may have been told that they have a “jumper’s knee.”

For many women, the conservative care treatments (anti-inflammatories, rest, ice, physical therapy) can be helpful, the woman with a physically demanding job will have their immediate knee pain reduced. However, like most runners or active people, or people with demanding lines of work, you kind of get used to nagging knee injuries and you always manage to work or get yourself through them as best you can.

Injuries do not become “real” injuries for most active people until such time that it becomes too difficult and painful to run or be active. At some point, you decide that you can no longer manage this pain on your own with over-the-counter pain relief medications, knee braces, and ace bandages so you go to a health care provider.

There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone) which causes the irritation and inflammation of the tissue. It is this location that also gives IT Band Syndrome, and it may be easier to understand the name “Runner’s Knee.” There are two distinct problems labeled “runner’s knee.” For problems that relate to Chondromalacia Patella – Patellofemoral Pain Syndrome please see that article.

Like many sports injuries, doctors tend to manage symptoms as opposed to fixing the problem of Iliotibial Band Syndrome

In the video below Ross Hauser MD explains that we see many patients at our center with problems of “Runner’s Knee,” or “Iliotibial Band Syndrome.” We typically see these people after they have tried many treatments with little to no success.

Iliotibial band syndrome is just one diagnosis and in wear and tear knee problems we usually find it is not an isolated diagnosis. There are more challenges in the woman’s knee.

Diagnosis: Patellar Tendinopathy

We have a more extensive article on our website Patellar Tendinopathy surgery and treatment options. We are presenting a summary of that article here:

Other knee tendinopathies

Please see our article Tendinopathy injections and treatments for a more extensive discussion on the knee tendinopathies we are discussing below.

Pes anserinus tendonitis

• One of the most frequent types of tendonitis of the knee is pes anserinus tendonitis, which involves the pes anserinus tendons that lie on the inside and just below the knee joint and prevent the lower leg from twisting outward while running. (Below the knee cap, on the inside of the knee, are the attachments of three tendons: semimembranous, semitendinosus, and gracilis. Together, these tendons create the pes anserinus area.)

Middle-aged adult runners are most susceptible to the development of pes anserinus tendonitis, the most common form. Two other types of knee tendonitis are popliteus tendonitis and semimembranous tendonitis.

Popliteus tendonitis

• Popliteus tendonitis is caused by excessive inward rolling of the feet, called pronation, as well as running downhill, which tends to put excessive stress on this tendon and can cause it to tear or become inflamed. Pes anserine tendonitis, on the other hand, is characterized by inflammation of the medial knee and often coexists with other knee disorders. Semimembranous tendonitis is characterized by swelling over the posteromedial aspect of the knee and tenderness with resisted flexion or outward-turned strain.

In treating tendonitis, which is occasionally misdiagnosed as bursitis, we recommend stimulating tendon repair and strengthening any weakened or lax ligaments with MEAT treatment, which consists of movement, exercise, analgesics, and treatment, as well as herbal supplements. This approach will encourage the damaged tissues to heal as quickly as possible.

Treatment guidelines – Exercise and physical therapy

A 2020 study published in the Journal of Back and Musculoskeletal Rehabilitation (8) examined women with knee osteoarthritis sought to determine the impact of aerobic exercise on functional limitation, exercise tolerance, and other performance tests on the quality of life. To do this researchers enrolled 50 women (aged between 48-78) with grade 2-3 knee osteoarthritis. Osteoarthritis-specific physical performance tests were then administered including a fast walk pace test, a test for standing and walking after getting out of a chair, and a stair climb test. The women’s ability to perform these tests was then assessed. Then the women were divided into treatment or non-treatment groups. The treatment group received additional aerobic exercise training along with a combined physiotherapy program for six weeks. The aerobic exercise program was carried out by the same physiotherapist every weekday (five days) for six weeks. The control group only received a combined physiotherapy program for six weeks.

Results: The post-treatment comparisons of the two groups showed the exercise group had reduced pain and disability scores and performed in the fast walk test. Consequently, this study provides an insight into the efficacy of the aerobic exercise program applied along with a combined physiotherapy program in postmenopausal women with knee osteoarthritis.

Treatment guideline – aquatic resistance training

All forms of exercise can be very beneficial. When research is published questioning the efficiency of a certain form of exercise many people who benefitted from it may write to us saying how much they were helped. A general rule is if something is helping you and you know it is helping you, it is a good thing.

A June 2020 study in the Scandinavian Journal of Medicine and Science in Sports (10) conducted an analysis to study the effects four months of aquatic resistance training have on self-assessed symptoms and quality of life in postmenopausal women with mild knee osteoarthritis after the completion of the study and after a 12-month follow-up period.

• A total of 87 post-menopausal volunteer women, aged 60-68 years, with mild knee osteoarthritis were recruited in a randomized, controlled, four-month aquatic training trial and randomly assigned to a control group or an exercise group. The exercise group participated in 48 supervised aquatic resistance training sessions over 4 months while the control group maintained their usual level of physical activity.

Results: After 4 months of aquatic resistance training, there was a significant decrease in knee stiffness scores in the aquatic resistance training group compared to the controls. After the aquatic resistance training was stopped, this benefit was no longer observed during the 12-month follow-up.

Conclusions: The results of this study show that participation in an intensive aquatic resistance training program did not have any short- or long-term impact on pain and physical function or quality of life in women with mild knee osteoarthritis. However, a small short-term decrease in knee stiffness was observed.

Treatment guideline – Bone Mineral Density and Osteoporosis in knee osteoarthritis

An August 2021 study in the journal BioMed Central Musculoskeletal Disorders (x) found that women who suffer from varus deformity (being bow-legged) were at greater risk for developing osteoporosis. Here are the summary learning points of this research:

• Varus deformity of the knee is a common pathological characteristic in knee osteoarthritis and not enough attention has been given to the relationship between knee varus deformity and the state of systemic bone mass.
• The purpose of this study was to evaluate the potential relationship between bone mineral density and varus deformity in postmenopausal women with knee osteoarthritis.

What is being suggested are the important topics of bone mineral density and knee osteoarthritis. Now let’s see how the connection was made to osteoporosis.

• A total of 202 postmenopausal women with more advanced arthritis were examined. Those women with varus deformity or bowed legs were compared to women who had normal limb alignment

Results: Bone mineral density within the knee varus deformity group was lower than of the normal limb alignment group, and the prevalence of osteoporosis was higher. Osteoporosis should be a major risk factor for varus deformity in postmenopausal women with knee osteoarthritis.

Treatment guideline – Vitamin D

In our article Vitamin D and knee osteoarthritis, we cite severe studies on the possible benefits of vitamin D supplementation for knee pain.

Doctors writing in the Archives of Osteoporosis (11) noted that:

• Low vitamin D status in knee osteoarthritis patients is often reported to be associated with increased pain and locomotor dysfunction (reduced ability to walk).
• Despite the growing evidence of the effect of vitamin D on the development and progression of knee osteoarthritis, vitamin D’s role remains conflicting. They concluded: “Vitamin D insufficiency may have an adverse effect on muscle power function.”

The effects of vitamin D supplementation on pain are controversial

In The Clinical Journal of Pain (12) researchers suggested:

• Because of the strong association between 25-hydroxyvitamin D levels and knee osteoarthritis pain, it is reasonable to think that vitamin D supplementation may help reduce pain affiliated with the condition.
• While some studies suggest that vitamin D does not regrow cartilage vitamin D supplementation did improve physical function assessed by a timed 20-meter walk and chair-rise test. In another study vitamin D supplementation in veterans was demonstrated to significantly decrease pain level, number of pain sites, use of pain medication, as well as improve sleep and health-related quality of life.
• The effects of vitamin D supplementation on pain in individuals with knee osteoarthritis are open to interpretation and warrant further investigation.

There is no general consensus on the effects of vitamin D on osteoarthritis, some results seem promising

As the above research points out, vitamin D does have a place in helping a patient with knee osteoarthritis. Vitamin D supplements are readily available and food rich in vitamin D is plentiful. These include salmon, herring, and sardines, for non-fish lovers spinach and kale. Of course, sunshine helps a lot too.

A study in the Orthopaedic Journal of Sports Medicine (13) concludes on what vitamin D may do: “Some studies have investigated the effect of vitamin D on osteoarthritis progression and pain management; however, while there is no general consensus on the effects of vitamin D on osteoarthritis, some results seem promising. Vitamin D supplementation may be a safe method to treat and prevent osteoarthritis, but future research is required to define the specific pathway and ultimate efficacy.”

Treatment guideline – Prolotherapy

Comprehensive Prolotherapy to the knee involves multiple injections of a dextrose-based solution directed at the affected tendons, ligaments, and other affected structures of the knee. This causes a mild and localized inflammatory response which triggers the immune system to initiate repair of the injured tendons and ligaments. Blood supply dramatically increases in the injured area. The body is alerted that healing needs to take place and reparative cells are sent to the treated area of the knee that needs healing. The body also lays down new collagen in the treated areas, thereby strengthening the weakened structures. Once the tendons and ligaments are strengthened, the joint stabilizes and the tendonitis or tendinosis condition resolves.

Platelet Rich Plasma Therapy is the use of a patient’s blood platelets and healing factors to stimulate repair of a tendon it is considered when tendon damage is more severe.

Chronic knee swelling is developing and worsening knee osteoarthritis

In this video Danielle R. Steilen-Matias, MMS, PA-C offers a brief summary of the constant degenerative process going on in your knee that shows itself every day to you as swelling.

Summary and learning points:

• The reason the knee is swelling relates to the strength or integrity or lack thereof of the soft tissue around the knee. So the knee swelling can be coming from knee ligament injury or instability. Your body, in an attempt to provide stability for the unstable knee, will swell the knee as a protective mechanism to provide stability to the need temporarily. It should be temporary. Your body is swelling the knee until healing of an injury can take place. The fluid fills the knee to also prevent excessive movement to accelerate healing. When the injury is healed the swelling goes away.
• If you do a job that is very physically demanding, you are on your feet all day, you climb ladders or steps, etc, that is a lot of strain to be putting on your knees and your body does the best it can to provide the swelling necessary to keep your knee together. The problem is chronic swelling is causing a rapid degeneration in the knee.

Questions about our treatments?

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References: 

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This page was updated January 29, 2022

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