Other types of arthritis that are less common in the elderly include rheumatoid arthritis, and arthritis related to other systemic inflammatory disorders. In some cases, problems in the spine can cause pain to be felt in the knees, even though there is nothing wrong with the knee joints themselves. An example would be pain from a slipped disc in the lower back.
Osteoarthritis is a chronic condition where the cartilage in the knee progressively wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can cause irritation in the joint as well as an overgrowth of bone, leading to the characteristic symptoms of knee osteoarthritis – pain, stiffness, and swelling. In more severe cases, there can be a sudden development of swelling in the knee due to a bleed from a blood vessel in the excess bone, or from irritation of the joint lining. This is usually associated with moderate to severe pain and difficulty bending the knee.
- Previous knee injury
- The knee is one of the joints that bears most of our weight. People who are obese have an increased risk of developing osteoarthritis in the knee.
- There is evidence that genetic factors may cause faster breakdown of cartilage.
- Racial factors. In Singapore, knee osteoarthritis is more common in the Chinese.
Knee pain is a common symptom with many possible causes in the elderly. The most common cause in Singapore is knee osteoarthritis. Other potential causes of knee pain in the elderly include acute knee injuries which cause bleeding in the joint, gout, and septic (infected) joints. Osteoarthritis is a “wear and tear” process of the cartilage in the knee which is very common. It occurs in many people as they age.
Understanding Knee Pain in Aging
The tendons are the tough cords that attach muscles to the bones. With age, the water content of tendons decreases, and the collagen fibers in the tendons can become unraveled. The tendons can become weakened and less able to tolerate stress. The ability of the tendon to repair itself decreases with age. The combination of these factors can lead to the inflammation of the tendons (tendinitis).
Cartilage serves as a cushion to the bones and provides a smooth surface for movement. With age, the cells of the cartilage lose their ability to retain water, the protein composition of cartilage degenerates, and the structure weakens. Severely overweight individuals can increase wear and tear of their knee joints as the excess load can cause the breakdown of cartilage. Inflammation of the knee joint lining can occur due to the wear and tear of the cartilage. This can cause the production of an excessive amount of synovial fluid, which can cause swelling and a feeling of “tightness” in the knee.
Causes of Knee Pain in Aging
The knee joint relies on a combination of bony anatomy, strong ligaments, and stable cartilage to function optimally. The anatomy of the knee consists of the distal end of the femur (thigh bone), the proximal end of the tibia (shin bone), and the patella (knee cap). These bony surfaces are covered with a thin layer of cartilage. There are two types of cartilage in the knee. The meniscus is a special type of cartilage with a rubbery consistency that acts as a shock absorber between the femur and tibia. Articular cartilage is a smooth substance that coats the end of the femur, the top of the tibia, and the back of the patella. This allows for easy movement of the joint. The cartilage is designed to glide smoothly against each other; however, various factors can damage the articular cartilage. When this happens, the joint becomes painful and difficult to move. Knee pain and problems moving occur when the joint is no longer able to distribute the load evenly. If there is a problem with the alignment of the joint, for example in people with bowed legs or ‘knock knees’, extra load is placed on one area of cartilage. This overloading causes damage to the cartilage and can lead to the development of osteoarthritis. Osteoarthritis is the ‘wear and tear’ type of arthritis that is common in elderly people, although it can affect younger people also. It is characterized by the degeneration of cartilage and the development of bony spurs at the margin of the joints. This causes pain and stiffness in the joint and can lead to deformity.
Osteoarthritis
Symptoms develop slowly and worsen over time. Pain may become mild to moderate and intermittent, without affecting everyday activity. At this stage, OA is often undiagnosed and is identified by chance when x-rays are taken for another reason. In some patients, symptoms may remain mild and increase the stability of the knee by forming bone spurs, which can be helpful. People who experience symptoms that are interfering with everyday life should seek medical advice, as there are remedies that may help without a need for knee replacement surgery. OA is observed through x-ray, and treatment is based around the relief of symptoms of pain and increasing function.
Osteoarthritis (OA) is the most common type of arthritis. Knee pain is a common symptom. OA in the knee can cause pain, stiffness, and swelling. It may limit your ability to bend and straighten your knee, walk, climb, or squat, and may cause limping. It often causes pain during climate change and a worsening pain at the end of the day. Sometimes the pain may wake you up at night. If the pain is severe, it may cause changes in your gait. These are symptoms of a damaged knee. OA is a degenerative joint disease, often associated with aging. The cause is complex and not entirely known. Factors include increasing age, heredity, gender (women have higher rates of OA), injury or overuse, and obesity. Step out of the shower and putting socks or stockings on may become painful and difficult.
Rheumatoid Arthritis
Rheumatoid arthritis is the most common form of inflammatory arthritis. In fact, it is thought that 1% of the general population suffers from this condition. The condition most often begins between the ages of 40 and 60, but can present at any age. In addition to causing joint problems, it is also a systemic condition that can affect other body parts and organs. It is 2-3 times more common in women than men and can run in families. It is caused by the immune system malfunctioning and attacking the lining of the joint (the synovium). This causes swelling, which over time can result in the destruction of the joint surface. Symptoms from inflammation of the synovium can present as pain, stiffness, swelling, warmth, and erythema (redness) of the joint. Systemic symptoms include fatigue, mild fever, weight loss, and anemia. In severe cases, RA can result in multiple joints being affected, and even primary joint replacement in the knee. Although studies have shown that when compared to the non-arthritic population, the lifetime risk of needing a knee replacement is only marginally increased. No specific cause of RA is known. In those genetically predisposed, it is thought to be triggered by an infection or exposure to a food or agent in the environment.
Gout
Gout occurs when urate crystals accumulate in the knees, causing knee pain and stiffness. Urate crystals form when there is a high level of uric acid in the blood. Uric acid is the waste product created when the body breaks down a chemical called purines. Purines are found in many of the foods we eat and also occur naturally in the body. It is normal for the body to create uric acid. However, in instances when there is either an overproduction of uric acid or the kidneys fail to excrete uric acid from the body, the uric acid levels can become high. When this happens, there is an increased chance of urate crystals developing, and in turn, gout. Urate crystals form in the body’s cooler areas, and for this reason, the knee is a common site of gout attacks. An attack of gout can be very intense and painful and is usually accompanied by inflamed skin, red skin, and warmth around the joint, and excruciating pain causing difficulty in walking. While some people will only ever experience one attack of gout, others will have recurring attacks. A common myth is that gout only occurs in an overweight older male, when in fact, it can happen to anyone and becomes more prevalent in women and men as they age.
Managing Knee Pain in Aging
Corticosteroid and Hyaluronic acid injections have a far more rapid onset of action and can be effective in managing knee pain caused by arthritis for several months. These injections are performed safely in the doctor’s office and involve little to no risk of complications. Corticosteroid is a type of steroid that can relieve pain and inflammation and can be injected into the joint or taken in tablet form. However, oral corticosteroid has numerous side effects, and long-term use of corticosteroid can have detrimental effects on overall joint health.
Analgesics are a simple and easy option for pain relief. However, for patients with chronic knee pain, analgesia is not a good long-term option as they can cause harm to the body with long-term use and may be ineffective in managing chronic pain. Glucosamine and Chondroitin sulfate are good options to relieve knee pain caused by arthritis. They are substances that are found in the body and help to repair damaged joint tissue. However, to date, there are still many conflicting studies on whether Glucosamine/Chondroitin is effective, and it can take several weeks to months for an effect to be seen.
These include: – Analgesics (painkillers) – Glucosamine and Chondroitin sulfate – Corticosteroid injections – Hyaluronic Acid injections – Physical Therapy
Non-Surgical Treatments
Various assistive devices can help with offloading the knee and improve mobility. Braces can improve stability and reduce symptoms for individuals with knee osteoarthritis. A recent network meta-analysis on the effectiveness of valgus bracing for medial compartment osteoarthritis of the knee has shown it to be effective in reducing pain and improving function. Full or unloader braces can reduce pain and instability in more severe osteoarthritis, often being recommended for individuals who are not candidates for surgery. Canes can also help reduce pain and improve function in persons with knee osteoarthritis, with one study showing that even a one-week usage of a cane significantly reduces the medial load on the knee.
Exercise – Exercise is a proven treatment for people with osteoarthritis of the knee. A study has shown that exercise significantly improves function and decreases pain in people with osteoarthritis of the knee. A recent OASIS study has shown that a strength training program is effective in decreasing pain and improving function in individuals with knee osteoarthritis. This was supported by a systematic review published in the Journal of Rheumatology Physical where it was found that participation in strength training programs significantly improves pain and function in individuals with knee osteoarthritis. A recent CPG published by the American College of Rheumatology has conditionally recommended aerobic, aquatic, or strength exercise for individuals with knee osteoarthritis who are considering treatment options.
Weight loss – Weight loss may be one of the most important treatments for knee pain. Weight loss can greatly reduce pain and function for overweight people with osteoarthritis of the knee. It is often the first line of advice to patients as simply advising people with painful knees to lose weight, assuming the person is overweight, may motivate individuals to undertake other strategies for pain relief.
Non-surgical treatment options are recommended to manage pain, improve mobility, and limit the advancement of osteoarthritis. An integrated approach combining different strategies usually works best. The following treatment options may be combined to achieve the best results.
Surgical Options
In general, surgery should always be an option of last resort. There are a very wide range of surgeries for arthritic knees. The most common is an arthroscopy. Sometimes this is the entire surgery, other times it is what is done to prepare the knee for something else. An arthroscopy does not heal arthritis. In arthroscopy, a few small incisions are made around the knee and a pencil-sized instrument with a camera on the end is inserted. Then the surgeon can inspect the knee and clean out any loose fragments of bone or cartilage. Then the most common and least invasive surgery is an unicompartmental knee replacement. The knee joint is divided into three compartments: the medial compartment, the lateral compartment, and the patellofemoral compartment. A person may have arthritis in only one of these compartments. In a unicompartmental knee replacement, only the arthritic part of the knee is replaced with metal and plastic. This is a less traumatic surgery as it requires a smaller incision and the bone that can be replaced is minimal. The recovery time and success rate in terms of removing pain is very good. The most common surgery is a total knee replacement. A knee replacement is when the whole joint is replaced with a prosthetic joint. Metal and plastic are used to create a smooth surface joint so bone-on-bone contact no longer occurs. This is a major surgery and the success varies. It is still a good option for people to consider as knee replacements are showing to last twenty years. The recovery time for knee replacements is around six to eight weeks. An osteotomy is another form of surgery. This is normally for younger people or people who do heavy lifting and are not ready to have a knee replacement; it is mostly to help delay having a knee replacement. An osteotomy is where a wedge of bone is removed from the shin or shin and the shin and thigh are then set to take pressure off the damaged part of the knee. Finally, there is arthrodesis, and arthrodesis is where the joint is surgically fused into a permanent position. This will take the pain away, but it will also create a leg that is stiff and cannot be bent.
Physical Therapy and Rehabilitation
Physical therapy is considered the cornerstone of non-surgical treatment for knee osteoarthritis. At all stages of the disease, physical therapy can help decrease pain, improve muscle strength to support the joint, improve range of motion and function, and enhance the quality of life. The physical therapist’s initial goal is to discover the patient’s specific problems and to what level these problems limit their desired activities or lifestyle. Once the therapist has identified the patient’s specific impairments, they will create a treatment plan tailored to the patient. Along with exercises, additional treatments include joint mobilization, hot/cold pack, ultrasound, and electric stimulation. Exercises will target the quadriceps and hamstring muscles in the upper leg and the muscles around the knee. It is important to note that before an exercise regimen, a warm-up with stationary cycling or swimming is advised to prevent additional stress on the knees. In general, the more the patients actively participate in therapy, the better their results. After self-managing the treatment plan for four to six weeks, the patient and therapist should re-evaluate potential benefits and what the next step in treatment should be. At this point, if the patient has not experienced any notable benefits, they should consider another form of treatment. If they have, they should continue with self-management and possibly create a new treatment plan. In the long term, the use of a physical therapy exercise program is an effective way to avoid surgery and limit aching joints. By increasing muscle strength to support the joints and improving flexibility, the knee will be able to better absorb shock. This will lessen the daily wear and tear on the joint and delay the progression of osteoarthritis.
Seeking Help from Singapore’s Geriatric Experts
At the current time, there are geriatric specialty services in two public hospitals; these are TTSH and SGH. Services at these two hospitals would be the most comprehensive.
As with geriatricians in other countries, there are a variety of practice settings: government, restructured hospital, private, community-based. Services of geriatricians working in hospitals or in the community can be accessed by getting a referral from another knee pain doctor Singapore. Those in private practice can be contacted directly.
For elderly individuals or their families who have questions or concerns about the suitability of medical treatment, it may be helpful to seek the advice of a geriatric specialist. This is particularly so if the individual is starting to experience the onset of multiple medical problems and/or some amount of incapacity.
Whether you are a young adult, middle-aged, or elderly, you do see your doctor for knee pain. If you are a young adult, chances are you have seen an orthopedic surgeon. Middle-aged individuals would have also seen an orthopedic surgeon or the general practitioner. The elderly have a higher chance of seeing an orthopedic surgeon, the general practitioner, and/or a geriatric specialist.
Choosing the Right Knee Pain Doctor in Singapore
The following are some questions that you might consider in choosing your knee osteoarthritis doctor: – What is the doctor’s level of expertise and experience in diagnosing and treating knee osteoarthritis? – Is the doctor board certified? – Is the doctor fellowship trained in osteoarthritis or sports medicine? – What are the treatment options provided by the doctor? – Is the doctor involved in any research in the field of knee osteoarthritis?
There are several types of healthcare professionals who provide treatment for pain due to knee osteoarthritis. These include orthopaedic surgeons, rheumatologists, physiatrists, and primary care physicians. In choosing the doctor that is right for you, a good place to start is to get a referral from a physician you trust. Once you have the names of a few doctors, the next step is to gather as much information as possible to make an informed decision. This can involve visiting the doctor’s website, talking to the doctor’s office on the phone, or scheduling an appointment for an initial consultation.
Geriatric Specialists in Singapore
Geriatric specialists are doctors who are skilled in the medical care of elderly people. They are often the best choice for treating chronic conditions that can affect aging individuals. Geriatric specialists will often incorporate a team of health professionals in addressing the health needs of older patients. These health professionals will focus treatment on the elderly patient’s ability to function independently. The increased prevalence of chronic diseases for the elderly means that geriatric specialists need to be familiar with an array of medical conditions and treatment. This is unlike many non-geriatric medical specialists who tend to focus on specific organs or body systems. Any condition that an elderly patient presents with is usually complex by nature and will require the specialist to consider multiple interrelated factors when devising treatment. This is usually because the body and its ability to function has a direct bearing on the onset and progression of the illness. Additionally, the illness and its treatment will often have a significant impact on the patient’s ability to function.
