Developing a Treatment Plan for Knee Pain

Knee pain is one of the most common patient complaints encountered by primary care physicians, orthopedists and pain management specialists. According to a recent study, frequent knee pain affects 25% of adults, with osteoarthritis being the most common cause in those over the age of fifty. But osteoarthritis is not the only cause of knee pain; thorough evaluation is imperative to achieve an accurate diagnose and, perhaps most importantly, an effective treatment plan. At SMART Pain Management our providers are experts in the evaluation and treatment of knee pain.

It is important to obtain a complete history, including timing of onset (sudden vs. gradual, acute vs. chronic; trauma, exposure history, etc.), pattern of onset (number of joints involved, symmetrical vs. nonsymmetrical,), location of the pain (medial, lateral, anterior, posterior, etc.), quality of the pain (aching, stabbing, shooting, etc.), radiation, severity, timing (during weight-bearing, nocturnal, etc.), aggravating factors, alleviating factors and extra-articular symptoms. Relevant information also includes the patient’s past medical and social histories.

A thorough history is coupled with a thorough physical examination of the knee by assessing for signs of inflammation, infection, ligamentous laxity, meniscal damage, effusion and bony deformities. One must also remember to examine the skin and other joints, as these may provide clues regarding the underlying etiology. In addition, various diagnostic imaging modalities may be warranted for further investigation, such as plain radiographs or MRI.

At SMART Pain Management, our providers skillfully gather and process the information gained from the patient’s history, physical exam and diagnostic imaging in order to arrive at an accurate diagnosis.

Treatment strategies include medications, physical therapy, bracing, joint aspiration, corticosteroid injections, viscosupplementation (hyaluronic acid) injections and genicular nerve blocks with radiofrequency ablation. A recent systematic review and meta-analysis of randomized, saline-controlled trials (Strand, et al) demonstrated that viscosupplementation provided significant benefit between 4 and 26 weeks for knee pain and function, and there were no statistically significant differences between viscosupplementation and controls regarding adverse effects.

Genicular nerve blocks are yet another interventional option for individuals with intractable knee pain that is refractory to conservative management, especially for those with persistent or recurrent knee pain after knee surgery. Genicular nerve blocks are performed by injecting local anesthetic outside of the knee joint, at the sites of the superior lateral genicular nerve, superior medial genicular nerve and inferior medial genicular nerve. If the patient has a positive diagnostic response to genicular nerve blocks, this may be followed by radiofrequency ablation (RFA) of the genicular nerves. The duration of pain relief following RFA is approximately 6 – 18 months, and the procedure can be repeated as often as every 6 months, if needed.

We perform most of our procedures with image guidance (ultrasound or fluoroscopy), in accordance with current evidence-based guidelines. Image guidance helps to assure that the needle is being placed precisely at the intended target, which significantly improves the safety and efficacy of the procedure. At SMART Pain Management, we strive to deliver safe and effective treatments that will ultimately lead to better results and more pain relief for our patients.