Introduction and Epidemiology
Knee pain is a very common problem that many people face. There are many causes of knee pain, but often, it is associated with some form of osteoarthritis of the knee, with which the relationship is complex. Knee pain can be distressing and widespread, with data showing overall prevalence as high as 46.2%, with the elderly being more affected by it.
Chronic knee pain can be managed symptomatically with many modalities. However, this is if there are no red flags in addition to the knee pain. Red flags indicate that the knee pain is the result of a more insidious process rather than osteoarthritic, degenerative changes leading to pain. Hence, presence of an underlying illness requires medical attention and a full medical workup should be sought. Red flags include conditions such as significant trauma to the knee, resulting in severe pain and swelling immediately. Dislocations of the knee are also emergencies that should be handled by emergency services. Other red flags include being very unwell generally in addition to the knee pain and having fevers, chills and rigors. Night pain is also a red flag symptom and knee pain that wakes you up from sleep should be discussed with a medical professional. Should you have other symptoms such as pain elsewhere other than the knee, as well as symptoms involving other organs, such as eyes, please seek a full workup from medical professionals. If your pain is something else other than chronic, gradual pain that is solely in the knees, an underlying disease may be present, which requires further medical attention. This article serves to provide evidence-based information to users and practitioners and is not a substitute for medical advice.
Knee pain can be due to a multitude of causes. Acute knee pain is most often due to trauma, infection or inflammation. These are suggestive of underlying diseases or require emergent treatment. Always seek professional medical advice for them. Chronic knee pain is caused most by degenerative changes in the knee, also known as osteoarthritis. Chronic knee pain may also be a result from referred pain, which is pain caused due to some problem elsewhere in the body. If you have any pain elsewhere or any doubts, do not hesitate to seek medical advice.
Knee osteoarthritis is a mechanical problem in joints that is often associated with degenerative changes. Hence, many a times, it is an isolated problem and can be treated non-surgically and even with alternative therapies. Thus, many people are likely to seek some form of treatment for their ailment, as having to live with constant pain in the knees is distressing. There are various available therapies that are aimed at reducing chronic knee pain, besides Western medicine. Some treatments are more effective than others and are backed with more evidence. Some therapies may have a faster duration of onset, but others may require that users utilize them for long periods of time before results kick in. Other treatments available may not be backed by evidence but may be beneficial. There are also those which have evidence suggesting that they do not really have a significant benefit to help knee pain. Ultimately, more studies must be done to find out more about each modality and how they work. The long-term effects of some modalities have also not been well studied and more research have to be done to evaluate the long term safety profiles.
Management – Conventional
Currently, treatment guidelines for osteoarthritis of the knee include lifestyle management advice, such as exercise, weight control and healthy diet. Pharmacological management include giving painkillers such as paracetamol or stronger non-steroidal anti-inflammatory drugs. For serious cases, interventional management or surgical management is sought. 
Management – Alternative Therapies
Based on current literature, there are numerous alternative therapies that patients can choose to treat chronic knee pain.
Many studies have evaluated the effectiveness of TaiChi in the treatment of knee pain. TaiChi has consistently been effective in reducing pain and improving function of those with knee pain. TaiChi even improves general well-being of users as well as promotes mental health. There are many postulated mechanisms on how this form of therapy can help with knee pain. For one, TaiChi is a form of physical activity which helps condition and strengthen various body parts, including bones and muscles, as well as improve blood flow. However, TaiChi is generally integrated into patients’ lifestyles and practiced over time before results are seen. This is alike how exercise has to be inculcated on a daily basis to promote healthy lifestyles and it is not a single-dose measure where one session of exercise brings about benefits straight away. Hence, it is not an immediate therapy for pain but focuses on general well-being and health to help with chronic knee pain. It must be noted that TaiChi should be done properly, with proper instruction from experts to prevent any injury or adverse events. Generally, there are no contraindications to TaiChi practice, so long as the exercises are catered to each individual and that the individual does not carry out unsafe, unguided movements.
Acupuncture is also another option to relieve knee pain. Studies have found that acupuncture often helps to relieve knee pain and improve function, but only in the short run. Many studies have found that the effect of acupuncture on knee pain is not prolonged, although the onset of effect is fast. Some studies also showed that acupuncture, in conjunction with Western medicine, specifically painkillers, helped with pain and function even more so than a single modality alone. This may suggest that there is a role for the integration of acupuncture with Western medicine. However, it must be noted that acupuncture should be done under licensed professionals, as there may be a very low chance of side effects such as bruising after the procedure. Generally, there are a few contraindications to acupuncture treatment and people with these conditions should avoid treatment. Namely, those with serious bleeding disorders, those with serious skin infections and those who are acutely sick and require emergency treatment. Those who are pregnant, on medications to thin blood and have abnormal heart valves should acupuncture or seek medical clearance prior to treatment.
Massage is also another option to relieve knee pain. Studies have found that patients undergoing regimens of massage, often for a course of a few weeks, show improvement in terms of pain and functionality. However, the effect of massage is also not prolonged, and it should be viewed more as a lifestyle change than a sole therapy for knee pain. Proper compliance and technique is also vital in achieving favourable outcomes for self-massage. There are various contraindications to massage as a therapy for knee pain. Those with the following conditions should avoid massage therapy and seek medical treatment. People who are acutely unwell and requiring emergency medical attention, such as those who have been through an accident and have severe swelling of the knee. People with infected skin around the area should also avoid going for massage therapy.
Yoga-based lifestyle is also another option for symptomatic relief. Studies have found that Yoga proved to have pain relief effects and is even useful in helping strength and flexibility of patients. In a study, yoga has even been used as an add-on therapy to conventional treatment of knee osteoarthritis, suggesting that there may be a role for integration of these modalities. Proposed mechanisms are like that of TaiChi, in that Yoga, being a form of physical activity, has the benefits that exercise has on humans, as well as certain motions to help specifically with strengthening and improving flexibility of the knees. However, likewise, Yoga is more of a lifestyle change to improve physical symptoms, but not a direct and rapid relief for knee pain. Different yoga poses and exercises have different contraindications. This is because different poses involve different body parts. For instance, those with recent knee injury should try to avoid yoga exercises that involve hyperextension, excessive twisting or generation of excessive force on the knee. This is because it may prevent the injury from healing. However, guided yoga exercises to strengthen the knee may be beneficial if done in a regulated and non-excessive way.
Ayurveda and Herbal
Ayurveda and Herbal medications have roles to play in symptomatic relief. Studies have shown that oral formulations have compounds that have medicinal effects, such as anti-inflammatory and immunomodulatory effects, which will help with knee pain. However, as this involves eating oral medication, before seeking treatment, patients must get their medication from trusted sources and professionals that know what ingredients and compounds make up the medicine. There is also a role to discuss with Western medicine practitioners if they are currently on Western medicine, as interaction between these drugs involve complex pathways that may interact and cause unwanted side effects. Furthermore, there are many forms of herbs and compounds in these modalities which are backed by different levels of evidence. Hence, it is best to check and discuss with the relevant professional practitioners prior to consumption of the drugs. Overall, treatment of knee pain due to ailments like osteoarthritis involve a chronic process and more studies must be done to show long term safety of oral formulations. Ayurveda and Herbal medications involve a vast array of oral formulations, each with differing amounts of compounds and different types of compounds. However, each compound has its own effects and as a result, there are many contraindications, depending on what drug one is on and what drug one is intending to take. Hence, it is imperative to discuss with healthcare practitioners about your individualised treatment.
Currently, there have not been many studies regarding homeopathy as a treatment of knee pain. A study did not show significant reduction in pain, stiffness, and loss of function between treatment and normal groups. Hence, more information is needed on the efficacy of homeopathy in treating knee pain.
To summarize, there are many modalities that can be used as alternatives for pain and symptom relief of knee pain. In fact, it is not uncommon for people with knee pain to turn to complementary and alternative therapies to manage their problem. However, many modalities are symptomatic treatments that provide relief to knee pain, which should be integrated into lifestyles instead of a once-off treatment. Based on current literature, these treatments do not provide mechanisms to cure the underlying knee condition of osteoarthritis that may be contributing to the pain. In order to prevent knee pain in the future, patients are encouraged to eat and live healthily from young and inculcate regular exercise and physical activity to strengthen muscles and bones. Please do discuss with your healthcare practitioners on your individualised treatment to fit your way of life and help you cope with joint pain, as individualized treatments help promote independence and will allow you to take ownership of your treatment.
DISCLAIMER: Always seek medical advice from your medical healthcare professional for proper evaluation prior to starting any form of treatment plan.
- Ho Yi Jie, National University of Singapore
- John Tan, National University of Singapore
- Kaye Tan, Singapore University of Technology and Design
- Pham Trung Viet, Singapore University of Technology and Design