Non-surgical Treatments

The knee is a complex joint which consists of bone, cartilage, ligaments and tendons that make joint movements easy and at the same time more susceptible to various kinds of injuries. Knee problems may arise if any of these structures get injured by overuse or suddenly during sports activities. Injuries to the knee can be caused by degenerative disease such as arthritis, traumatic injuries and sports injuries. These conditions may affect the bones & joints and impair the mobility as well as the quality of life of the patients. All these conditions require appropriate treatment, may be surgical or non-surgical to restore to normal activities. The non-operative orthopedic treatment options include non-pharmacological and pharmacological interventions. They are aimed at providing symptomatic relief and improving the quality of life of the patients. They can be used as a treatment option to treat certain conditions or to decrease pain as well as promoting functioning and quality of life after the surgical treatment.

Pharmacological interventions

Pharmacological interventions include management of pain using medicinal preparations such as pain relieving capsules or injections.

• Non-steroidal anti-inflammatory drugs - These are known as NSAIDs and are found to be effective in reducing pain and inflammation of the knee. Caution must be taken while using NSAIDs for overdosing as they are known to cause hepatotoxicity. Patients with liver diseases must have extreme care while using them. They cause a range of side effects, chances of which increase with the concomitant use of diuretics, angiotensin converting enzyme inhibitors, angiotensin 2 receptor blockers, anticoagulants or oral corticosteroids.
• Weak and strong opioids - Opioids are prescribed when use of analgesic medications or NSAIDs does not offer symptomatic pain relief, if other treatments have intolerable side effects or in whom the surgery is delayed or contraindicated. Though they offer better pain relief they are known to cause side effects such as dry mouth, nausea, vomiting, dizziness and constipation. Overdose may lead to respiratory depression. The dose is reduced slowly otherwise cause withdrawal effects. They are also known for addiction.
• Disease modifying anti-rheumatic drugs and biological agents - Disease modifying anti-rheumatic drugs (DMARDs) aim at halting the progression of disease and offer symptomatic relief. Biological agents are the antibodies against the disease-causing agents manufactured using genetic engineering technology. These agents are recommended in individuals with severe disease condition.

Our blood consists of a liquid component known as plasma. It also consists of three main solid components which include the red blood cells (RBCs), white blood cells (WBCs), and platelets. Platelets play an important role in forming blood clots. They also consist of special proteins, known as growth factors, which help with our body's healing process. Platelet-rich plasma or PRP is a high concentration of platelets and plasma.  A normal blood specimen contains only 6% platelets, while platelet-rich plasma contains 94% of platelets and 5 to 10 times the concentration of growth factors found in normal blood, thus greater healing properties.

Indications

PRP is a relatively new method of treatment for several orthopedic conditions such as muscle, ligament, and tendon injuries; arthritis; and fractures. PRP injections can help alleviate painful symptoms, promote healing and delay joint replacement surgeries.

Procedure

Your doctor will first draw about 10 ccs of blood from the large vein in your elbow. The blood is then spun in a centrifuge machine for about 10 to 15 minutes to separate the platelets from the remaining blood components.

The injured part of your body is then anesthetized with a local anesthetic. The platelet-rich portion of your blood is then injected into your affected area. In some cases, your doctor may use ultrasound guidance for proper needle placement.

Post-Procedural Care

• It is normal to feel some discomfort at the injection site for a few days after your procedure.
• You will be prescribed pain medications by your doctor.
• You may use cold compresses to alleviate your symptoms.
• You will be instructed to stop any anti-inflammatory medications.
• You may resume your normal activities but should avoid any strenuous activities such as heavy lifting or exercises.

Risks and complications

There are very minimal risks associated with PRP injections. Some of the potential risks include

• Increased pain at the injection site
• Infection
• Damage to adjacent nerves or tissues
• Formation of scar tissue
• Calcification at the injection site

Viscosupplementation refers to the injection of a hyaluronan preparation into the joint. Hyaluronan is a natural substance present in the joint fluid that assists in lubrication. It allows smooth movement of the cartilage covered articulating surfaces of the joint.

Synvisc is one of the most commonly used hyaluronan preparations. It is indicated in the management of shoulder, knee, hip or ankle osteoarthritis that has not responded to non-surgical treatment options such as pain medications, physical therapy and corticosteroid injections.

Synvisc provides symptomatic relief and delays the need for surgery. It is injected directly into the joint to replenish the diminished synovial fluid, thereby enhancing its lubricating properties. A single dose or a total of three separate doses of Synvisc, over several weeks, may be required for optimum benefit.

Some patients may experience mild pain, swelling, warmth and redness at the injection site for up to 48 hours following a Synvisc injection. Headache and joint stiffness may also occur in some cases. Ice packs and an analgesic may be used, if required, to ease the discomfort. Any strenuous activity such as jogging or tennis should be completely avoided for 48 hours to a week after the injection and should be resumed only after consultation with your doctor.

Synvisc injection not only supplements the hyaluronan in the joint but also stimulates the production of hyaluronan in the treated knee. This provides gradual symptomatic relief over the course of the injections. This effect may last for several months.

Please note: Immediately consult your doctor if you develop fever or the pain and swelling fail to resolve after 48 hours following the injection.

Cortisone is a corticosteroid released by the adrenal gland in response to stress and is a potent anti-inflammatory agent. Artificial preparations containing cortisone are injected directly into the affected joint to relieve pain and reduce inflammation. The effects may last for several weeks and cortisone injections are recommended in injuries that cause pain & inflammation and those don’t require surgical treatment. One such condition frozen shoulder and cortisone injection into shoulder joint relieves pain & inflammation.

Cortisone injections offer significant relief in pain & inflammation however is associated with certain adverse effects. The most common side effect is a “cortisone flare”, a condition where cortisone crystallizes and cause severe pain for a brief period that lasts for a day or two. Cortisone flare can be minimized by applying ice to the injected area. Other adverse effects include whitening of the skin and infection at the injection site, a transient elevation in blood sugar in patients with diabetes.

Physiotherapy or physical therapy is an exercise program that helps you to improve movement, relieve pain, encourage blood flow for faster healing, and restore your physical function and fitness level. The main aim of physical therapy is to make your daily activities such as walking, getting in and out of bed, or climbing stairs easier. It can be prescribed as an individual treatment program or combined with other treatments. Physiotherapy is usually ordered to help you recover after certain surgeries, injuries and long-term health problems such as arthritis. It involves a combination of education, manual therapy, exercises and techniques such as water, heat, cold, electrical stimulation and ultrasound.

For knee problems, therapy involves strengthening and stretching certain joints and muscles. Physical therapy for the knee is designed to improve muscle strength of the knee and reduce pain. Some of the exercises recommended for knee problems are:

• Straight leg raise: Lie on your back, bend one leg at your knee, and hold the other straight and lifted off the floor for a slow count of 5. This can be done twice a day.
• Step ups: Step onto the first step of the stairs with your right foot. Bring up the left foot and step down with the right, followed by the left. Repeat this exercise until you get short of breath. As you improve, try to increase the number of steps.
• Knee squats: With the support of a chair or work surface, squat until your knee covers your big toe and stand. Repeat the exercise at least 10 times. As you get more comfortable, try to squat a little more.
• Knee extensions: Sit at the edge of the chair and gently slide your operated leg forward straightening it. Hold this position for about 10 to 15 seconds and return to the initial position.
• Passive knee extension: For this exercise, you need 2 chairs placed opposite to each other. Sit on one chair and rest your leg on the other. Keep a rolled towel under your ankle and an ice pack over the knee. Place 5 to 10 lbs. weights over the knee for a recommended amount of time.
• Straight leg raise: Lie on your back on a flat surface with your arms resting by your side. Use your forearms to support your upper body and raise your legs 12 to 20 inches off the ground. Hold this position for about 10 seconds and then slowly bring it back to the initial position.
• Ankle pump: In this exercise, sit on a flat surface with your legs stretched out and slowly move your foot forward and backward as far as possible.
• Quadriceps stretch (standing): Stand straight with one hand on the wall for support. With the other hand, hold your heel and bend your affected knee towards your buttocks to feel a stretch in front of your leg.
• Step ups: Step onto a stool with your involved leg and step down. The stool can be placed in front of you or beside the injured leg.
• Pedal on an exercise bike and go walking.

You can discuss with your physiotherapist any questions you may have regarding the exercises to be performed. You can begin with basic exercises and then move on to more advanced ones. It is important to strictly follow the schedule and practice only those exercises prescribed by your therapist.