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 lead 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 activities that they want to return to. They are not confident in the knee replacement and its ability to get them back to the sport.
The problem with opioids among middle-aged women vets
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 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 are 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 “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 we 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:
Understanding points: People will often come into the office with confusion because they have been diagnosed with patellar tendinosis or with patellar tendinitis.
- Patellar tendinitis is inflammation, pain, and swelling.
- Patellar tendinitis occurs, for instance, when a runner has knee pain after a run or as mentioned above involves jumping or lunging as in aerobic type workout.
- Patellar tendinosis is pain and weakness without inflammation.
- This is a chronic degenerative condition. If this woman gets a cortisone shot in the patellar tendon or they take anti-inflammatories for a very long time, the tendinitis (pain and degenerative knee disease symptoms with inflammation) becomes tendinosis (pain and degenerative knee disease symptoms without inflammation).
As mentioned previously, this list of knee problems is usually not an isolated knee injury. The problem of patella tendinopathy is that is part of a series of problems in the knee caused by knee instability.
Many people have patellar tendinopathy. They take some anti-inflammatories, look up video exercises, buy tape and knee braces and they go about their way with a chronic nagging injury that they can pretty much control.
Cortisone injection concerns
A recent paper in the International Journal of Sports Physical Therapy (3) offered this summary of the concerns of using cortisone for patella tendinopathy.
- “As tendon pathology has been historically labeled as tendinitis, an inflammatory condition, it is not surprising that anti-inflammatory medicines are commonly prescribed for patients with tendon pain. This includes the use of oral non-steroidal anti-inflammatory medicines (NSAIDs) and injections of corticosteroids. In a systematic review of the literature on the treatment of tendinitis,(one study) reported that the use of oral NSAIDs may result in some pain relief but the effect on the tendon is not known as the follow-up time in all the studies was less than one month. Similarly, the use of injected corticosteroids may also result in pain relief in tendinopathy, but there is concern regarding the effect of corticosteroids on tendon strength.”
The main problem with patellar tendinopathy – is it a degenerative disorder rather than an inflammatory disorder – should you have surgery?
If the doctor suggests your problem is due to patellar tendinopathy, you have a problem with the tendon that passes from the quadriceps muscle (the large muscle at the front of the thigh) over the kneecap (patella) to connect to the shinbone (tibia).
What are we seeing in this image?
The patella is pulled and pushed in all directions. It is pulled by the Iliotibial band, it is stabilized in place by the lateral patellar retinaculum and the medial patellar retinaculum. The quadriceps move the patella upwards, the patellar ligament moves it downward. When one of these structures is weakened or damaged through degenerative wear and tear, the knee cap becomes unstable.
Let’s look at a paper from the Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore. It was published in the journal Annals of Translational Medicine,(4) October 2019.
In this paper, various methods of treating common knee injuries are discussed. One section has very good information on the concept of the patella and the importance of keeping the patella where it should be in the knee.
“Patellar taping is commonly used in conjunction with manual and exercise therapies in the management of Patellofemoral pain syndrome. Taping is predominately used to help decrease pain. Other studies show it can also help with patellar alignment and muscle activation. As patellar hypermobility has been shown as a predisposing factor for developing Patellofemoral pain syndrome, taping can be indicated to promote patellar positioning and decrease pain. . . .Overall, the effects of taping, are conflicting, with some studies showing no benefit and others unsure of the mechanisms of improvements noted. The positive changes including decreased pain and improved VMO (vastus medialis obliquus, the muscle above the knee used to extend the leg at the knee and to stabilize the patella) function is only short-term but can be helpful with acute management of symptoms with functional activity.”
The goal of tape or brace or surgery is to get the patella back into place.
Non-surgical solutions to the problem of chronic and recurrent Patellar Tendinopathy
In Germany, doctors published research suggested that treatment with platelet-rich plasma showed a significantly better outcome when used correctly. Additionally, treatments such as Extracorporeal shockwave therapy, operative treatment, and sclerotherapy (Prolotherapy) have also shown positive effects. Treatment with corticosteroid injections and with oral non-steroidal anti-inflammatory drugs (NSAIDs) showed positive short-term effects. (5)
Prolotherapy which is explained and demonstar6ted in a video below can treat various knee disorders including problems of the tendons. Prolotherapy Injections of a dextrose solution directed at the weakened tendons and involved ligaments. This causes a mild, localized inflammatory response at the injured area which stimulates a string of healing events, which include an increase of blood supply, an influx of reparative cells, and the deposition of collagen cells. When the collagen matures, it will strengthen and tighten the damaged tendons and ligaments.
A quick word on Patellar Tendinopathy and ligament weakness
- Chronic patella pain and tendinosis are rooted in knee instability. Upon examination, we find patients who have patellar tendinitis may have laxity in the anterior cruciate ligament (ACL), medial collateral ligament (MCL), or a posterolateral ligament injury.
- The ligaments are the primary stabilizers of the knee. If the knee is unstable, the patellar tendon will be under strain and weaken.
To address this, a series of injections are placed at the tender and weakened areas of the patella tendon and knee ligaments. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction. The body heals by inflammation, and Prolotherapy stimulates this healing. As the ligaments tighten and the patella tendon heals, the knee structures function normally rather than moving out of place. When the knee functions normally, the pain goes away.
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 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.
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 at 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.
A Meniscus tear from nowhere
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 breakdown 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 the people will 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.
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.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This page was updated April 1, 2021