The knee is a very complex joint between the ends of the femur, the thigh bone which ends in two bulges, the medial and the lateral femoral condyles which are coated with cartilage, and the leg bones, the tibia and the fibula. On the front of the tibia is a bump called the tibial tuberosity in which the patellar ligament inserts. The patella or kneecap is embedded in the patellar ligament and the quadriceps tendon. The quadriceps tendon joins the three parts of the quadriceps, the vastus medialis, the vastus lateralis and the rectus femoris which is in the middle, directly underneath it. Inside the knee joint, resting on the tibial plateau (the upper part of the tibia), are the medial and lateral menisci two cartilaginous ridges each in the shape of a half circle on either side of the tibial plateau which guide the femoral condyles when the knee flexes. In the center are the anterior and posterior cruciate ligaments which prevent the tibia moving too far forward (anterior cruciate ) or backwards (posterior cruciate) when the knee is flexing. When a joint has this many parts, you can expect wear and tear on it to cause a great deal of damage. This damage, in turn, is likely to cause a great deal of pain.

What Causes Knee Pain?

Some knee pain comes from your back or your hip. Consult these sections for more details. Hip pain Sacroiliac pain Back pain

Pain in the knee itself, can either be acute (of short duration) either from trauma or infection or chronic (long-lasting). A knee infection, in which you knee is red hot swollen and tender, is a medical emergency. You should immediately make your way to the emergency department of a hospital. If you have just injured your knee, unless it is a mild sprain of one of your collateral ligaments, you should consult a physician and have your injury attended to as soon as possible. In this section, we will concern ourselves with chronic knee pain.
The commonest cause of chronic knee pain is arthritis. Three kinds of arthritis plague the knee: collagen disease, the most common of which is rheumatoid arthritis. Other kinds of collagen disease can affect the knee including lupus and scleroderma. X-rays and blood tests can tell you whether you have rheumatoid arthritis or another form of collagen disease. Crystalline arthritis, gout, due to uric acid crystals and pseudogout due to calcium pyrophosphate crystals in the knee joint can produce severely painful attacks of arthritis. The most common form of knee arthritis is osteoarthritis. People with osteoarthritis, wear and tear arthritis, usually wake up with pain and stiffness in their joints in the morning which gets better during the day as they move but tends to get worse again with prolonged motion. The condition gradually gets worse and can cause bone deformity around the joints.
Patellofemoral syndrome: when the knee flexes, the patella tracks between the two femoral condyles. If the tibial tuberosity, the protuberant knob on the front of the tibia where the patella attaches, is not aligned with the groove between the femoral condyles, either because of a congenital malformation, or because you have knock knees, usually from overpronated feet, or bow legs, then the patella will rub against one of the femoral condyles. This will be painful when you flex your knee, and may wear down the patella where it is rubbing, causing chondromalacia patella.
Osgood-Schlatter disease: a form of jumpers knee that occurs in adolescence and is due to the fact that the thigh bone, the femur is growing faster than the quadriceps muscle which attaches on the patella then on the tibial tuberosity with the patellar tendon. The excessive pull of this tendon on the tibial tuberosity frays it and causes it to be tender when it is touched. As time goes on the tuberosity grows and starts to protrude in an attempt to hold on to the patellar tendon. This problem generally stops when the adolescent stops growing.
Jumper’s knee: tendinopathy of the quadriceps tendon where it attaches, either at the upper margin or the bottom of the patella or on the tibial tuberosity. It causes pain which is worse on jumping up than on landing, and is usually seen in people who do a lot of jumping such as basketball or volleyball players.
Bursitis: The bursa is a fluid filled pouch between a bone and muscle or two muscles. When it gets inflamed it fills with fluid and may be painful. This inflammation can be the result of trauma, infection, or crystalline deposits. The commonest form of bursitis is prepatellar bursitis, “housemaids knee”, due to prolonged kneeling. Occasionally, the bursa under the pes anserinus gets inflamed “anserine bursitis”, usually in people who are overweight.
Iliotibial band syndrome: from your ileum, on the outside of your pelvic bone, a thick white band courses down the side of your thigh and attaches on the upper part of your tibia. When this band is tight, it rubs on the lateral femoral condyle and this can cause pain. The pain usually afflicts long distance runners after about 10 minutes of running and is relieved by rest.

Nerve damage can also cause pain in the knee: sometimes the nerves that supply the skin of the knee can be injured through a sudden jolt, or through a sprain. Prolonged or very strenuous exercises, such as marathon running, can jar the nerves in your legs cause these nerves to swell and become painful. The nerves that supply the skin of your knee have to cross the fascia, the fibrous sheath covering the muscles of your legs through tiny holes. A sudden jolt can stretch the fascia and distort these holes, which become slits. These slits squeeze the nerves and cause them to swell. Prolonged rubbing of the nerves against these holes can also cause them to swell. Once swollen, the nerves are trapped in these holes and cannot slim down, as they keep re-injuring themselves on the walls of these holes. As long as they remain swollen, these nerves will send pain messages to the brain. This pain can spread down the leg, first to the area below the knee, then to the ankle and foot, and can last for many years. Pain due to loose ligaments or tendons or arthritis only comes when you move the ligaments or tendons or the joints. Nerve pain, on the other hand, can be severe and happen at any time even when you are not moving at all. If you press lightly on an area with nerve pain, the pain gets worse. Many people suffering from knee pain have been successfully treated with perineural injection therapy (nnerve blocks). Because this treatment is very safe, it is worth trying at least once, particularly if your pain has not been helped by other treatments.

Knee Pain Treatment

Obviously, the treatment for pain in the knee depends on the cause. Certain treatments, however are the same for all painful knee conditions. If you look at the osteoarthritis section, the same treatments pertain with a few exceptions.
Obviously, the treatment for pain in the knee depends on the cause. Certain treatments, however are the same for all painful knee conditions. If you look at the osteoarthritis section, the same treatments pertain with a few exceptions.

Prolotherapy as a treatment for pain in the knee. Prolotherapy, a series of injections of growth promoting substances in and around the joint has been shown to be effective in osteoarthritis of the knees. It has been shown to stimulate the growth of ligaments, including the knee’s ACL, and tendons as well as cartilage. You can make cartilage 65% thicker with prolotherapy. Even the knee’s meniscus has been shown on ultrasound to regrow with prolotherapy.

Walter Grote, Rosa Delucia, Robert Waxman, Aleksandra Zgierska, John Wilson, David Rabago. Repair of a complete anterior cruciate tear using prolotherapy: a case report. International Musculoskeletal Medicine 2009 Vol 31 No 4 159-165 Serial MRIs document the regrowth of a completely torn ACL following prolotherapy. The last MRI shows a normal looking ACL.

Bradley D. Fullerton, MD High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases Arch Phys Med Rehabil Vol 89, February 2008 377-385. Serial MRIs and ultrasounds show the repair of a patellar tendon, an ankle ligament and the medial meniscus of the knee using prolotherapy.

Reeves, KD,Hassanein K, randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxityAltern Ther Health Med 2000; 6:68 80. Those treated had significantly less pain and swelling and increased range of motion as well as evidence of regrowth of cartilage one year later on x-ray. http://www.drreevesonline.com/Knee%20Arthritis%20Study.pdf For a summary, go to http://www.ncbi.nlm.nih.gov/pubmed/10710805
Collagen diseases such as lupus and rheumatoid arthritis are chronic inflammatory conditions. In addition to pain medication, patients need to take anti-inflammatory medications as well as anti-metabolites, such as methotrexate aimed at retarding the disease’s progression. I have recently treated a woman with extensive rheumatoid arthritis with 5% dextrose injections in her joints, and immediately freed her from her pain and gave her full range of movement. This treatment needs to be investigated.

Crystalline diseases, such as gout, which causes severe inflammation because of micro crystal deposits around the joints also need anti-inflammatory medications, as well as medications to help reduce the amount of uric acid and other sources of micro crystals in the patient’s system.

Bursitis: can be treated with protection of the bursa against trauma, resting the area, icing and a compression bandage. If this fails to help you may need a steroid injection in the bursa. The risk is that the bursa could become infected and need to be removed surgically.

Chondromalacia patella: can be treated with exercises to balance the muscles around the patella, but the most effective treatment is usually orthotics. Orthotics correct overpronation which causes knock knees, the commonest reason chondromalacia happens. Dr. Bertrand can fit you with a guaranteed pair of orthotics. If the tibial tuberosity is truly misplaced, the patellar tendon may have to be surgically repositioned.

Jumpers knee and Osgood-Schlatter syndrome: can be helped by rest and slowly progressive exercises to strengthen the quadriceps and hamstring muscles. Possibly the best treatment you can have is prolotherapy as it can repair the damaged ligaments and their attachments to the bone. Most physicians will recommend icing and the use of anti-inflammatory medications, (see Nonsteroidal anti-inflammatory references). Please read the section on osteoarthritis to find out why this might be counterproductive.
Obviously the best way to treat illiotibial band syndrome is to stretch the iliotibial band. One way to do this is to place the right leg behind the left while standing with your left side about 2-3 feet from a wall. Then, lean toward your left for 20-30 seconds using the wall to help you support yourself. Most physicians will recommend icing and the use of anti-inflammatory medications. Please read the section on Nonsteroidal anti-inflammatory references to find out why this might be counterproductive.

Prolotherapy References