Knee pain treatment · Metro East
There is a pad of fat inside your knee that behaves like a gland. When your metabolism is inflamed, so is your knee, and the knee pain follows.
Knee osteoarthritis is not a tire wearing down. It is a joint being chemically inflamed from inside and from the bloodstream. The treatment has to answer both before anyone talks about replacing it.
Is knee arthritis wear and tear or inflammation?
Under the kneecap, between the tendon and the joint, sits a lump of fat the size of a walnut. For a century it was called padding. It is not padding. It is a metabolically active tissue (it makes chemical signals) that releases the same signal molecules as belly fat: leptin, interleukin-6, tumor necrosis factor. When the body’s fat stores are inflamed, so is this one. It drips those signals straight into the joint fluid an inch from the cartilage. The synovial lining (the joint’s inner skin) responds. It thickens and starts making the enzymes that dissolve cartilage. That is why the rheumatology literature now insists osteoarthritis is arthritis and not arthrosis: the ending matters, because the process is inflammatory.
The second driver is the bloodstream. High insulin, high triglycerides and glycated (sugar-coated) proteins reach the cartilage from the bone beneath it. They stiffen the collagen and starve the chondrocytes, the cells that keep cartilage alive. The evidence that this is chemistry and not just weight is the hand. Across more than 1.7 million adults followed in one cohort, obesity raised the risk of hand osteoarthritis right alongside knee and hip. Nobody walks on their hands. The knee simply gets both hits at once, the chemical one and the mechanical one, which is why it is the joint that fails first.
The third driver is the job. Ten hours on a concrete floor at a distribution center. The steps of a truck cab forty times a shift. Kneeling through a plumbing career. A stretch of afternoons at a steel works. Each adds load, and each comes paired with the schedule and the food that inflame the fat pad in the first place. A knee that hurts at the end of a warehouse shift is answering to both, and the plan has to as well.
Does a torn meniscus on my MRI explain my knee pain?
Most knee MRIs in people over forty describe a torn meniscus and thinning cartilage. So do the MRIs of people whose knees do not hurt. A pooled analysis of adults with no knee pain and no injury found cartilage defects in about one in four. It found a meniscal tear in about one in ten, rising with age. The report describes a forty-year-old knee. It does not diagnose why yours hurts. The exam is what separates them. Where does it hurt? Is the joint warm and swollen? Is the pain on the joint line, on the fat pad, or on the tendon below the kneecap? Are the hip and the back quietly adding to it?
SAME DAY, NOT THIS CLINIC
A knee that is hot, swollen and too painful to bend, with a fever or after a recent injection. A knee that locks and will not straighten. Inability to put weight on it after a fall or a twist. Calf swelling and tenderness on the same leg. A lump that is growing. Each of these is a different problem with a shorter clock; this page says where it belongs.
How is knee pain treated without surgery?
THE TERRAIN AND THE LOAD
In a randomized trial of 454 overweight and obese adults with knee osteoarthritis, eighteen months of diet plus exercise cut interleukin-6. It reduced pain more than exercise alone, and the diet arms lowered the compressive (squeezing) force across the knee. That is the fat pad and the bloodstream both being treated. Here it is prescribed with its mechanism. The acellular carbohydrates and the industrial seed oils go first, because they are what keeps the insulin and the inflammatory signaling switched on. Loading comes in, because cartilage has no blood supply and is fed by the pumping of the joint as it moves. Sleep is protected, because short sleep lowers the pain threshold and raises the next day’s inflammatory markers. A licensed, pain-trained behavioral clinician delivers Acceptance and Commitment Therapy in-house here, because the pattern that ends in a replacement usually runs through avoidance first. This is 40 to 50 percent of the protocol, and it starts on the first visit.
INTO THE JOINT, UNDER IMAGING
Image-guided injection puts the medication where the needle was aimed. Steroid buys a short window. It raises blood glucose for days, which in this population is not a footnote. Hyaluronic acid and PRP [platelet-rich plasma, your own concentrated platelets] are options with different mechanisms; most payers do not cover PRP, which is a payer decision and not a verdict on the evidence. Which one, and whether at all, depends on what the exam found. It also depends on what the bloodwork says the joint is sitting in.
THE NERVES THAT REPORT THE KNEE
Three small nerves carry most of the pain signal from the knee. They can be tested with a genicular nerve block. If the block turns the pain off for an afternoon, radiofrequency ablation of those nerves can turn it down for months. A double-blind randomized trial found it did so in patients with chronic knee osteoarthritis pain. No sedation, drive yourself home, back to normal activity within two to four hours. It is the option for three people: the one not ready for a replacement, the one who is not a candidate for one, and the one who has had one and still hurts.
Joint replacement is a good operation for the right knee at the right time. The surgeons who do it well are colleagues. Our job is to make sure the knee that goes to them is the one that needed it. It is also to make sure the metabolic terrain it comes out of is not the one that made the first joint fail.
Can I choose my own doctor for a knee injured at work in Illinois?
A knee injured on a loading dock in Edwardsville or a mill floor in Granite City is an Illinois workers’ compensation case, administered by the Illinois Workers’ Compensation Commission, and an injured worker may generally choose their own physician within the two-choice rule in 820 ILCS 305/8(a) unless the employer has an approved preferred provider program. That is a statement of the rule, not advice about your case, which belongs with an attorney or the IWCC. This page covers how a work injury is documented here, and why the block results matter more than the MRI in that file.
Orthobiologic treatment options
For the arthritic knee, PRP, bone marrow concentrate and microfragmented fat aim at the inflamed joint chemistry this page describes. Two things decide how long the result holds: the platelet dose that reaches the joint, and the thigh-muscle rehab afterward. You stay awake under local anesthetic, and most people drive home across the river the same day. Coverage is a plan budgeting decision, and HSA and FSA funds can generally be used.
Pain right below the kneecap, worst on stairs and squats, is often the tendon in front of the joint, not the joint itself. That one has its own page: patellar tendonitis. If the outer hip hurts too, read hip bursitis.
Common questions
Do I need a referral for knee pain treatment?
No. Knee pain visits are booked directly, with no referral and no MRI needed first. A few insurance plans, mostly HMOs, want a referral from your primary doctor on file before they pay, so check your card. Knee pain that will not quit often has a blood sugar story; why we check your blood sugar explains the link.
Can losing weight really change knee pain if the cartilage is already gone?
Pain in an arthritic knee tracks inflammation in the lining and the fat pad. It tracks that more closely than how much cartilage is left. And the inflammatory signals fall as insulin and triglycerides fall. The metabolic page explains what changes and how fast.
How is a genicular block different from a steroid shot?
A steroid injection goes into the joint to calm the lining. A genicular block goes to the nerves outside the joint. It tests whether interrupting them stops the pain, so it is a diagnosis as much as a treatment.
Why does my knee hurt more at night when I am not using it?
Inflammatory signaling in the joint runs on a daily clock and rises in the early hours. The joint stiffens without the pumping of movement. And short sleep drops the threshold at which the brain reports pain. Sleep and movement are treated as part of the knee plan for that reason.
Can radiofrequency ablation help after a knee replacement?
Lasting pain after a well-placed replacement is common enough to have its own body of research. And the genicular nerves are still there. A diagnostic block tells us whether ablation is worth doing in that knee.
What causes knee pain without an injury?
Usually three drivers at once. The fat pad under the kneecap acts like belly fat and releases inflammatory signals into the joint. High insulin, high triglycerides and glycated proteins reach the cartilage from the bone beneath it and stiffen the collagen. And the job adds load: long shifts on concrete, climbing truck steps, kneeling. A knee can fail from this chemistry and load with no single injury behind it.
Is walking good for knee pain?
Movement is part of the treatment. Cartilage has no blood supply and is fed by the pumping of the joint as it moves. A knee left still stiffens and hurts more. Loading is prescribed here, because avoiding movement is the pattern that usually ends in a replacement. The exception is a knee that locks, will not bear weight, or is hot and swollen. That needs same-day care.
How is knee pain diagnosed?
With an exam first, because most knee MRIs past forty describe a torn meniscus or thinning cartilage, painful or not. In adults with no knee pain, about one in four have cartilage defects and one in ten a meniscal tear. The exam finds where it hurts and whether the joint is warm and swollen. It shows whether the joint line, fat pad, tendon, hip or back is to blame. A genicular nerve block tests the nerves when the exam leaves doubt.
Related reading
- Genicular nerve block
- Image-guided joint injections
- Hip pain
- Metabolic health and pain
- Injured at work
- Patellar tendonitis
- PRP injections and the other orthobiologics we use for Metro East patients
Sources
- Berenbaum F. Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis and Cartilage, 2013. PubMed 23194896
- Courties A et al. Metabolic syndrome-associated osteoarthritis. Current Opinion in Rheumatology, 2017. PubMed 28072592
- Reyes C et al. Association Between Overweight and Obesity and Risk of Clinically Diagnosed Knee, Hip, and Hand Osteoarthritis: A Population-Based Cohort Study. Arthritis and Rheumatology, 2016. PubMed 27059260
- Culvenor AG et al. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British Journal of Sports Medicine, 2019. PubMed 29886437
- Messier SP et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA, 2013. PubMed 24065013
- Choi WJ et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain, 2011. PubMed 21055873
You will be examined before your MRI is believed
We will tell you which structure in the knee is producing the pain, what the bloodwork says the joint is sitting in, and what each step is for. If the honest answer is that the knee is ready for a surgeon, you will hear that too.
505 Buckeye Dr, Suite 200
Troy, IL 62294
Procedure clinic: 4499 Woodson Rd, St. Louis, MO 63134, off I-70 next to St. Louis Lambert International Airport. One bridge from the Metro East.