The bulk of people who attend our clinics for knee pain have been diagnosed as having arthritis in some form or another. In most cases this can be attributed to the natural wear and tear process but it can still a disabling condition that may affect anyone becoming especially common as we get older.
It may come as no surprise that some estimates put the incidence of arthritis in the over 50’s as high as 8 out of 10 but the process of cartilage thinning can start much earlier than that. To understand why the knee is so prone to arthritis we need to get to grips with the knee anatomy.
Knee Anatomy – Why it can go wrong
In essence, the knee is simply two blind-ended bones coming together and held in place by numerous soft tissue structures. Unlike the hip, the knee has no socket to give it stability and is therefore inherently unstable. It relies totally on ligaments, tendons and muscles to keep it together. Now add to this the effects of gravity squashing us on a daily basis, our own body weight, the compressive effect of the powerful leg muscles as they contract and compress the joint during walking and running, and the damaging jarring effects of hard surfaces and it is easy to see that 50 years of such abuse will take its toll on the knee. These factors act on the normal knee in day-to-day life before we even considered the abnormal effects of sports such as football, running, horse riding and skiing all of which bring their special strains and stresses to play on the joint.
All in all, the knee puts up a brave fight. It has a tough layer or cartilage and two anatomical space fillers called menisci. These half moon shaped pieces of cartilage increase the surface area of the knee and help to spread out the load more evenly. They are, however, prone to getting caught between the bones of the knee during odd twisting movements and becoming damaged or torn. If this occurs you know all about it! The pain is acute and the knee often locks so you are unable to straighten it. There is much swelling and it is impossible to weight bear on the joint. I have seen many of these injuries and they are not easy to treat.
The meniscus can, in some cases, be replaced by joint manipulation but they invariably come out again and more often than not require surgery. Time has moved on and knee surgery is now very straightforward. Using arthroscopic techniques a torn meniscus can be easily removed with minimal disruption to the joint and minimal risk of infection. In the case of an acute tear of the meniscus there is often no alternative. Luckily, they are not that common and the degenerated knee far outnumbers them.
Looking for Clues
If we accept that joint degeneration is one of those things that naturally occurs with age and use, looking for a “cure” becomes unrealistic. Treatment of the arthritic knee needs to be viewed as a healthy balance between self-help and natural therapy. A knee that shows signs of early arthritis can be prevented from degenerating further with simple and common sense advice and treatment. With all knee pain the first place to look for clues is at the feet! These are the foundations for the body and any aberration in their structure or alignment will throw the balance out and place eccentric stresses and strains on all the weight bearing joints, including then knee. I am constantly amazed at the number of patients I see who have been through the medical-mill of GP, consultant and physiotherapist, none of whom have ever examined the patients feet. If you walk with a flat foot or a high stiff arch you are asking for trouble from the knees in time. In the case of flat foot the arch drops. As this occurs the lower leg twists inwards placing the knee in a strained twisted position. The knee cap then moves across the front of knee joint in an oblique fashion when it should be moving simply in an up and down direction. This odd “patella-tracking”, as it is known, starts the degenerative process off. I commonly see it in pre-teen and teenage girls, especially those who are sporty. In this age group the cartilage is still quite soft and malleable, but pain soon establishes itself often curtailing promising sporting aspirations. The problem is known as chondromalacia patellae. Some medical estimates places its incidence at 2 in every 10,000 but I feel it is more common than that and may go undiagnosed, often put down to “growing pains” or an aversion to sports in overweight sports-phobic children. However, it is a real problem and one that needs to be taken seriously. Missing this diagnosis may predispose the sufferer to early degenerative changes in later life since the incidence of chondromalacia peaks again in the early 40’s when, I feel, the symptoms are more due to early degenerative changes. In any case, early detection is essential and can be corrected with special exercises, orthotic shoe inserts and the use of cartilage protective agents such as glucosamine and esterified fatty acids. The correct balance between these two agents needs to be assessed in the clinic and depends on the type of pain that presents.
If we return again to the older knee, foot structure and function is just as important. A flat foot will not function as an effective shock absorber nor will a foot with a high arch. Both these feet need special support with an individualised orthotic. Getting the foundations right is vital if the knee is ever going to feel good.
Working up the leg we come to the knee itself. In cases of early arthritis there may not be much to see but the margins of the joint are commonly tender to touch and there may be some crunching and cracking as the knee bends and straightens. In more advanced cases obvious bony swellings can be seen and the knee looks very sorry for itself, often stuck in a knocked-knee posture. I am regularly amazed at how the appearance of the knee offers little indication to the level of pain felt. Some knees are so bent and knarred but the owners simply report a vague ache whereas another pair of knees, with hardly an outward sign, can be wracked in agony. You can see how knees are mostly treated on the grounds pain. A severely deformed arthritic knee that is aching but not actually painful can be very effectively managed with acupuncture and natural medicines such as Knotgrass Complex. A monthly clinic visit is all that is needed in most cases and the use of potentially hazardous anti-inflammatory drugs completely avoided. With so many people taking a mini aspirin for circulatory problems the concurrent use of anti-inflammatory drugs for arthritis places the gut in real danger of ulceration and bleeding. Avoiding long-term use of anti-inflammatory drugs is essential especially if you are taking the mini aspirin.
Moderate Knee Pain
For those knees that fall into the moderate category, things get a little more complicated. The sufferer has pain that must be addressed but is also in a position where further degeneration is inevitable if other measures are not taken. For these knees an aggressive exercise plan is needed to strengthen the muscular structures that run across the joint. Remember that the knee is only as stable as its soft tissue support. Weak thigh muscles offer little or no support and allow for excessive “joint-play” that accelerates the degenerative process. Muscle strengthening and conditioning is essential. To ease the more acute phases of a moderate case of knee arthritis a combination of Harpagophytum and esterified fatty acids helps take the heat out of the joint. These natural anti-inflammatory remedies are safe on the stomach. They may take a little longer to take effect but the long-term outcome is far better and the body can tolerate them very well. Acupuncture has now been shown to offer significant pain relief in cases of knee arthritis. A recent issue of the journal Acupuncture in Medicine devoted an entire supplement issue to the published studies all of which showed very encouraging results and outcomes from around the worlds. The photo above shows my approach to treating degenerative arthritis using electro-acupuncture. In this case the inner part of the knee (medial joint space) was painful and tender to touch. However, this chap responded very well to the treatment.
Complementary Treatment and Hard Science
There is always a problem with acupuncture studies and hard science; how do you give placebo acupuncture? However, in the real world of the clinic where patients vote with their feet I know that acupuncture works in the fight against knee pain where other treatments have, more often than not, failed.
Between clinic visits the home exercise plan can be supplemented by the use of alternate hot and cold packs. This basic hydrotherapy helps boost circulation and eases the accumulation of irritant toxins. Applying our special hot-pepper cream also helps ease the stiffness and bone aches associated with joint degeneration. Applying the cream causes a deep warming sensation and effects the action of substance-P within the spinal cord. Substance P is a fascinating substance known as a neuropeptide. It was discovered and reported back in 1931 when its role was somewhat mysterious. Now, almost 70 years later it is probably one of the most investigated and well-understood pain transmitting substance. By the end of the 80’s substance P was shown to exert powerful actions within certain areas of the spinal cord. The hot stuff in our cream is known as Capsaicin. This has been shown to reduce the levels of Substance P in many studies by altering its actions withing the spinal cord. Apart from the hot and tingling effect of this cream it is safe and effective. A few people who have very sensitive skins find the heating effects intolerable but for most the pain relieving effect is profound.
When it comes to the knee the medical outlook is rather bleak; take pain killers and if these don’t work try anti-inflammatories; if these fail or you get side effects wait 15 weeks for physiotherapy; if you are in too much pain try a steroid injection; if you don’t fancy that then join the list to see the surgeon for a new knee! In some cases surgery may be the only way but these cases are in the minority. For most knees the natural approach offers a better outcome with negligible side effects and is well worth a try!
1) High volume acupuncture clinic (HVAC) for chronic knee pain – audit of a possible model for delivery of acupuncture in the National Health Service
2) A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee
3) Trigger point acupuncture for treatment of knee osteoarthritis – a preliminary RCT for a pragmatic trial