Knee Pain


Bruce N., Tarzana, California, 2011. Tendonitis.

Bruce is a 54 years old junior high school teacher, suffered from pain in his both knees for about six months. He trained in long walking preparing for the “walk for the breast cancer” held every summer in Santa Barbara. His goal is to walk for 25 miles for the activity. Unfortunately, pain in his knees prevented him to continue the training. X-ray of the knee did not show any pathology in the joints. Tendonitis was diagnosed. Acupuncture treatment was started on 5/25/2011 on both of his knees. After the fifth treatment, he went back to his training started with walking continuously for 3 miles. His condition was improving progressively with acupuncture and he was ready for joining the activity without pain in his knees after 16 treatments were given on 8/5/2011.  

Structure of the knee

The knee joint is a weight-bearing joint and it functions to allow movement of the leg and is critical to normal walking. The knee joint has three parts.

1. The bones—Femur of the thigh connected with the tibia of the lower leg to form a main joint. Each protrusion of the lower end of the femur contacts to the tibia to form two joints. The patella (kneecap) stay in front of the joint joins the femur to form the third patellofemoral joint.

2. The ligaments—The joint is surrounded by a joint capsule with ligaments strapping inside (medial collateral ligament) and outside (lateral collateral ligament) the joint. Two other ligaments strapped within the joint firmly attached to the femur on one end and the tibia on the other (anterior and posterior cruciate ligament). The function of the ligaments is to provide stability and strength to the knee joint.

3. The meniscus– The meniscus is a thickened cartilage pad between the two joints formed by the femur and tibia. The maniscus functions as a smooth platform for the joint to move on. Bursae are fluid-filled sacs sit around the joint which serve as gliding surfaces that reduce friction of the tendons.

The quadriceps muscle located in front of the thigh extends the knee joint. The knee normally has a 0 degree of extension. The hamstring muscle located in the back of the thigh flex the knee. Normally the knee joint flexes to a maximum of 135 degrees.

Causes of knee pain

1) Trauma. The knee joint is an active weight-bearing joint and the complexity of the design is factors in making the knee one of the most commonly injured joints.

 Fracture— Breakage of any of the three bones of the knee joint can occurred during major trauma, such as motor vehicle accidents an impact trauma.

 Meniscus tears— The meniscus can be torn during sharp, rapid motions. This is common in sports requiring reaction body movements. With aging and degeneration of the cartilage creates higher incidence of tearing. It is often associated with locking or unstable sensation in the knee joint. Sometimes, inflammation or swelling is associated.

 Ligament injury— One of more ligaments can be injured in a single traumatic event. Local pain on the area of individual ligament involved. Pain, swollen and warm can be experienced. Pain is usually at rest and worsened by bending, weight bearing or walking.

2) Inflammation.

 Arthritis—Rheumatoid arthritis or gout arthritis are inflammatory types of arthritis. Ostoarthritis is due to degeneration of the cartilage and it is a type of non-inflammatory arthritis.

 Tendinitis—Tendinitis is an inflammation of the tendon of muscle which is often produced by a strain, such as jumping.

 Brusitis—Brusitis commonly occurs on the inside of the knee and the front of the kneecap.

3) Infection. Infection of the bone or joint commonly is associated with fever, chill, or warm of the joint. Infection of the joint can rarely be a serious cause of pain.

Management of Knee pain

For acute trauma the principle of treatment is the same as any sport injury that is RICE, rest, ice packing, compression and elevation. Analgesic might be used for pain. For infection especially accompanied with open wound, antibiotics might be prescribed.

The role of acupuncture in knee pain therapy

  • Acute conditions—Treatment of fracture of bone, rupture of meniscus or complete tear of ligament many time surgery is the only immediately procedure to do.
  • Subacute stage – Pain or swelling of knee joint after trauma acupuncture will be help to relieve pain and swelling to improve the knee function. Fluid accumulation due to trauma or post-operation, clinical experiences demonstrated electo-acupuncture provides a very good result.
  • Chronic pain — According to National Institution of Health, more than 4 million people seek medical care for a knee problem each year. Patellofemoral pain syndrome (PFPS) is one leading cause of chronic knee pain. PFPS occurs particularly in young adults who participate in sports and is one of the most common diagnosis given at orthopedic centers and sports medicine clinics worldwide. No single therapy, as to date, has been shown to be completely effective in treating PFPS. Acupuncture, however, has shown promising result on knee pain treatment and may be it is an alternative treatment for patients suffering from PFPS.
  • Osteoarthritis– Osteoarthritis is a second only to cardiovascular diseases in producing chronic disability. As life expectancy rises, there are more patients being referred with advanced osteoarthitis of the knee. For many the treatment of choice is total knee replacement. Of those considered, some may be unfit for major surgery, and those are fit inevitably spend months on a waiting list, or consume a great amount of resource. Acupuncture has been shown to be effective in relieving pain in advanced cases of osteoarthritis of knee

What we do

Standard steps we approach to patient with knee pain:

1. Record detail history of illness to sort out the cause of the pain.

2. Review test data and imaging result (X-ray, CT scan, MRI).

3. Perform physical examination and movement test to picture the illness tissues.

4. Propose a treatment plan.

5. Common acupuncture points used include: Ear liver, knee; Sp 10, St.36, Sp9, Liv 3, Du-bi.  6. Electric stimulation added as need.

 

Demography of knee pain patient and treatment results of our clinic

Study data draw from 2003 to 2007. Age: 45 to 80, average 63. Gender: F: M=3:1

 

Diagnosis

% of total pain patients

% of Improvement

% of marked improvement

Average treatment

Knee pain 7.72 91 87.9 10

 

Literature review

Chen G, et al. The application of electroacupuncture to postoperative rehabilitation of total knee replacement. Zhongfuo Zhen Jiu 2012 Apr;32(4):309-12.

Seventy cases of total knee replacement of knee osteoarthritis were randomly divided into two group, an acupuncture-rehabilitation group and  rehabilitation group, with 35 cases in each. In acupuncture-rehabilitation group, routine rehabilitation therapy combined with electroacupuncture therapy was applied. The acupoints selection was mainly based on pathological location. In rehabilitation group, routine rehabilitation therapy was applied. The functions of affected knee in both groups were evaluated by artificial total knee replacement scale of the New York Hospital for Special Surgery (HSS), range of motion (ROM) of affected knee, Visual Analogue Scale (VAS) of pain and Manual Muscle Test (MMT) before, and 2, 6 and 12 weeks after surgery. The result shown rehabilitation therapy combined with electroacupuncture can obviously restrain the pain during rehabilitation process for total knee replacement patients, improve the endurance capacity of rehabilitation training and motivation, and obviously promote the recovery of total knee joint function

Mayrommatis Cl, et al. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed, randomized, placebo-controlled trial. Pain.  2012 Aug;153(8):1720-6. Epub 2012 Jun 21.

Single-blind, randomized, sham-controlled trial. This study was to designed to compared the effect of acupuncture combined with pharmacological treatment, sham acupuncture including pharmacological treatment, and pharmacological treatment alone. A total of 120 patients with knee osteoarthritis were randomly divided into 3 groups: group I was treated with acupuncture and etoricoxib, group II with sham acupuncture and etoricoxib, and group III with etoricoxib. Several parameters were used to determine the effects at the end of 4, 8, and 12 week. Group I exhibited statistically significant improvements in primary and secondary outcome measures, except for Short Form mental component, compared with the other treatment groups. It has concluded that acupuncture with etoricoxib is more effective than sham acupuncture with etoricoxib, or etoricoxib alone for the treatment of knee osteoarthritis.

Cao L, et al. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi Med J 2012 May;33(5):526-32.

The authors searched PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials databases from July to October 2011 for randomized controlled trials that compared needle acupuncture with sham acupuncture, standard care, or waiting list control groups in patients with knee osteoarthritis to evaluate the efficacy of treatment with acupuncture for knee osteoarthritis. Of the 490 potentially relevant articles, 14 RCTs involving 3,835 patients were included in the meta-analysis. .

Compared with sham acupuncture control treatment, acupuncture was significantly better at relieving pain and restoring function in the short-term period, and relieving pain and restoring function in the long-term. Compared with the standard care and waiting list control treatments, acupuncture was significantly better at relieving pain and restoring function.

White A, et al. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (oxford)  2007 Mar;46(3):384-90. Epub 2007 Jan 10.

Systematic review and meta-analysis of randomized controlled trials of adequate acupuncture. Computerized databases and reference lists of articles were searched in June 2006 to evaluate the effects of acupuncture on pain and function in patients with chronic knee pain.

Studies were selected in which adults with chronic knee pain or osteoarthritis of the knee were randomized to receive either acupuncture treatment or a control consisting of sham acupuncture, other sham treatments, no additional intervention, or an active intervention. The main outcome measures were short-term pain and function, and study validity was assessed using a modification of a previously published instrument.

The results shown acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional intervention in improving pain and function in patients with chronic knee pain.

Jensen R, et al. Acupuncture treatment of patellofemoral pain syndrome. J Altern Complement Med Dec. 1999;5(6):52d1-7

Seventy patients from age 18 to 45 randomized assigned into an acupuncture group or a control group. The control group contained 34 patients with 21 female, average age of 33.4. The acupuncture group contained 36 patients with 20 female, average age of 29. All patients in the acupuncture group received needling treatment at the ST-36 and SP-10 acupoints. Several other points also used depending on each patient’s diagnosis, twice a week for 4 weeks, with each session lasting 20 to 25 minutes. Patients were evaluated both before and after treatment using the Cincinnati Knee Rating System (CRS). The CRS measures symptoms of pain, swelling, and function on a scale of 1-100. A higher score means fewer signs of injury or pain.

Within 6 weeks, the CRS scores for patients in the acupuncture group improved 4.2 on pain, 5.1 on function and 6.5 on symptoms. Improvement demonstrated in the acupuncture group continued in the 5-month and has higher score than the control group. The measurements of the 12-month showed the CRS scores for patients in the acupuncture group improved 6 on pain (control group 1.9), 6.8 on function (control 1.9) and 10.3 on symptoms (control 3.7). A different of CRS, Global score for acupuncture treated patients is 17.2 which is far beyond the score for control group 5.6.

This study is one of the largest treatment studies on the PFPS, and it shows a clear, durable effect of acupuncture treatment in reducing pain and improving function for the patient.

Christensen BV, et al. Acupuncture treatment of knee arthrosis. A long-term study

Ugeslr Laeger 1993 Dec 6:155(49):4007-11

29 patients with a total 42 osteoarthritic knees were randomized to two groups. Group A was treated with acupuncture while group B served as a no treatment control group for nine weeks. In the second part of the study 17 patients (26 knees) continued with treatment once a month for a total period of 49 weeks. There was a significant reduction in pain, analgesic consumption and in most objective measures in the acupuncture group. The range of movement of the knee demonstrated a significant increasing.

Abhay Tillu, et al. Effect of acupuncture on knee function in advanced osteroarthritis of the knee: a prospective, non-randomized controlled study. Acupuncture in Medicine 2002:20(1):19-21

This prospective control trial, comparing acupuncture with no treatment, is to evaluate the effectiveness of acupuncture in patients with advanced osteoarthritis of knee awaiting total knee replacement. 75 consecutive patients on the waiting list for a total knee replacement were contacted and asked to participate in the study. Patients who received arthroscopic washout within 6 months, intra-articular steroid injection to the knee within 3 months, acupuncture treatment within one year and inflammatory arthritis were excluded from this study.

37 consecutive patients were allocated to group A receiving acupuncture treatment and next 38 patients to group B receiving no treatment. Four local points around the knee and one distal point were used for needling. All the needles stimulated 4 times during 15 minutes of treatment. All patients received acupuncture treatment at weekly intervals for 6 weeks.

Measured the effects using the Hospital for Special Surgery (HSS) knee score, time taken to walk 50 meters, time taken to climb 20 steps, and a visual analogue pain score (VAS). 60 patients were successfully completed the trial, 30 in the treatment group (female 60%, average age of 73.6) and another 30 in the control group (55% female, average age of 74.6). The results of this trial demonstrated the acupuncture treatment group improved in all parameters, whereas the control group deteriorated, a finding that was highly statistically significant. In the acupuncture group at two months follow up, the time to walk 50 meters, climb 20 steps, and the pain scores, fell and the HSS scores increased. The converse was found in the control group. Symptoms in three patients in the acupuncture group improved to the extent that they requested suspension from the waiting list of knee joint replacement.