You may know that acupuncture successfully treats back pain, but may not be aware it also treats many other types of pain, including that of the knee.
Today’s blog will discuss knee anatomy, common painful conditions, and how they are treated, from a conventional medicine and Traditional Chinese Medicine (TCM) point of view.
The knee is a complex hinge joint connecting the femur (thigh bone), tibia (shin), fibula (on the outer side of the shin), and patella (kneecap). It is lubricated with encapsulated synovial fluid that protects the bones from rubbing against each other, similar to the function of oil protecting moving parts in a car. Several fluid-filled sacs called bursae reduce friction within the knee as well.
The knee is designed to bear our weight, while providing movement. It takes stresses we may put upon it, from walking on a level surface, to running up and down stairs, lifting heavy weights, or playing football or hockey. It is stabilized by ligaments and cartilage, which protect and keep the knee lined up so it can function optimally. They include:
- Medial and lateral meniscus—these are crescent shaped shock-absorbing discs that allow knee movement so that the bones don’t rub against each other. They are supplied by nerves, which help us balance;
- Articular cartilage: more shock-absorbers, located on the bony surfaces within the knee joint;
- Medial and lateral collateral ligaments (MCL and LCL)— these keep the knee from moving from side to side;
- Anterior and posterior cruciate ligaments (ACL and PCL)—prevent the knee from sliding forwards and backwards.
The patellar tendon, which connects the kneecap to the quadriceps muscles, also provides stability to the joint.
Even certain muscles have an impact on how our knees function. The quadriceps muscle group which are the thigh muscles that straighten our legs, the hamstrings which bend our knees, and even muscles in our buttocks, the gluteus medius and minimus all affect the position of the knee joint and surrounding area.
Injury to any of these structures, including that due to arthritis, can cause pain, which may be localized or refer to the thigh or lower leg. The most common injuries, often due to exercise, sports or falls include:
- Injuries to the ligaments (sprains, strains). The ligaments most affected are the ACL and MCL. Both of these injuries may have common symptoms and may be hard to tell apart. An ACL tear is common in sports where the knee may be twisted suddenly, as in football, soccer, or baseball. Popping (which is heard in about 80% of those affected) is followed by pain, which may be severe. The knee can be stiff and may feel like it is giving away when walking is attempted. An MCL tear most often occurs in contact sports. When injured, a popping sound may be heard and the inner part of the knee is often painful. It feels as if the knee will give out when weight is applied, and may lock. Injury is graded by the severity of the injury, grade 1 involving a stretched ligament, grade 2, a partial tear, and grade 3, a full tear.
- A meniscus tear, though most often seen in sports, can occur with any type of activity involving the knee. Squatting, twisting, and direct contact can injure this cartilage. It can tear in 3 ways, including bucket handle, flap and radial presentations. People may feel a pop, and over 2-3 days the knee will gradually become more stiff and swollen. Most can still walk on their leg. The knee may lock, give way, and it is difficult to move bend the knee fully in either direction.
- Patellar tendinopathy, often referred to as Jumper’s Knee, as excessive jumping or landing stresses the tendon the most, is an overuse injury. It often affects athletes in sports such as basketball, volleyball, soccer, football, track and field (running, long jump, high jump), tennis, dancing, gymnastics, and skiing. Older people can also have this injury. Here, the pain is worse with activity and is localized above the kneecap. It is often more stiff in the morning. Pain is gradual in onset, and the tendon may crunch or be enlarged.
- Arthritis of the knee most often affects us as we age. Osteoarthritis is a degenerative “wear-and-tear” disease most often seen in people over 50. Here, the cartilage wears away leading to bones rubbing on bones, and can produce spurs. It develops slowly over time, and can be very painful. Some patients present with pain only when weight-bearing. Others have pain throughout their waking hours. Swelling and stiffness is common and it is often worse in the morning or after long periods of sitting and resting. Creaking, clicking, snapping, or grinding noises may be heard with movement. The knee may stick or lock, and in severe cases it may bow outward. Many people with osteoarthritis of the knee and other joints will often feel worse when the barometric pressure drops.
- Baker’s (popliteal cyst). This is a fluid-filled swelling that forms a bump behind the knee, which results in tightness, restricting movement. It is often painful when bending or straightening the leg. In most cases, it is due to an underlying arthritis or cartilage injury. In severe cases it can rupture, leading to a “bruise” around the ankle.
TREATMENT OF KNEE PAIN
Treatment of knee pain depends on its causes. Anyone with a painful knee, especially in acute injury, should be seen by a doctor to assess the severity.
Treatment of acute injury such as sprains, strains, and tears involve R.I.C.E. The joint should be rested, ice applied the knee compressed, or wrapped, and elevated to reduce swelling. It should be noted that application of ice is a topic that is being hotly debated by many practitioners who see healing times slow down with its use.
Non-steroidal anti-inflammatories (NSAIDs) such as naproxen (Aleve®) or ibuprofen (Advil®, Motrin®) can be given for pain and swelling. These medications should be given with food to decrease stomach upset and help prevent gastrointestinal ulceration or bleeding from occurring. These medications also increase the risk of heart attack and stroke, with or without risk factors or pre-existing heart disease, and should not be used when taking blood-thinners, and may aggravate asthma. For severe pain, more potent opiates/opioids are used carefully, according to the BC College and Physicians and Surgeons pain management guidelines. It should be noted that NSAIDs and opiates/oids do not treat the cause of the pain.
Acupuncture, which I will be discussing in more length below, physiotherapy, platelet-rich plasma (PRP) or stem cell therapy can speed up the healing process, though more research needs to be done on PRP and stem cell therapy as success is still not yet medically proven. Surgery may be required in severe conditions.
For popliteal cysts, RICE, acetaminophen, NSAIDs, or corticosteroid injections (which can actually degrade the joint with repeated use), are the mainstays of treatment. Usually the cyst is left alone and will go away once the underlying cause is treated. In severe cases the doctor will drain the cyst with a needle. As popliteal cysts are usually due to other knee problems, the underlying cause should be addressed. Acupuncture and physiotherapy are beneficial in treating pain and speeding up the healing process.
Osteoarthritis treatment though similar, has a few differences compared to acute injury of the knee. Heat is applied unless there is an acute flare-up, where ice may be more helpful. Land-based exercise and weight loss, when needed are also suggested. Acetaminophen (Tylenol®) and/or NSAIDs or the Cox-2 inhibitor celecoxib (Celebrex®) may be given for pain. Corticosteroid injections, while temporarily effective, can cause further degradation of the joint with repeated use. For severe pain, opiates/opioids are used carefully to avoid addiction, according to the BC College and Physicians and Surgeons pain management guidelines. Tai Qi, acupuncture, TENS (transcutaneous electrical nerve stimulation) and intra-articular hyaluronate injections are recommended by the American College of Rheumatology.
PRP, or stem cell therapy, though promising, are still of questionable efficacy especially in the long term. In arthritis, a small study involving 14 patients showed some relief at 4 months after 3 treatments of PRP but the conclusion was that more study was required. Compared to the injections of corticosteroids, viscosupplementation, or autologous mesenchymal stem cell injections, PRP was deemed to be more favourable. Stem cell therapy, though promising, remains controversial until more valid studies are published.
For knee pain due to tension in the gluteus minimus, gluteus medius, hamstrings, or quadriceps muscles, yoga, stretching, acupuncture, massage, and/or physiotherapy can be of benefit.
ACUPUNCTURE AND TRADITIONAL CHINESE MEDICINE’S ROLE IN KNEE PAIN
Acupuncture and Traditional Chinese Medicine (TCM) can be beneficial when treating all of the above knee pathologies, both acute and chronic. Practitioners examine the knee, observe the quality of pain and symptoms present, and search to understand the underlying contributive factors.
When there is pain of the muscles, tendons, ligaments, and/or joints, a diagnosis of “Bi” syndrome, which translates into “painful obstruction syndrome,” is made. Bi syndrome is a result of construction in the flow of Qi and Blood in the affected area. The resulting pain, considered to affect the outside of the body, is caused by External Pernicious Influences, such as Wind, Heat, Cold, and Damp, which often combine with each other and cause different symptoms. Wind Bi typically involves pain that moves in the body, and can cause spasms. It is the spearhead of disease, bringing Heat, Cold, and/or Dampness to the affected area. Wind-Heat Bi is the type of pain that, when combined with Damp, involves swelling and inflammation. It worsens as the day wears on, and with repeated movement of the joint. Wind-Cold Bi symptoms include stiffness, decreased range of motion and is the type of pain that gets better with warmth and some movement. Patients suffer most in the morning and often feel better as the day moves on.
Bi syndrome knee pain is most often seen when there has been an injury to the knee, repeated over-use, and repeated wear and tear of the joint/spur formation, which is the case in osteoarthritis.
There can be other pathologies that lead to or aggravate Bi pain of the knee in TCM. When people age, or have a poor constitution, they can have what is termed “Kidney Deficiency” and have these symptoms: Fatigue, tinnitus, decreased hearing, premature hair loss or graying, forgetfulness, chronic low back and/or knee weakness, and thinning bones, the latter two which can further exacerbate knee pain. There are other TCM patterns that may aggravate knee conditions, including Qi and Blood deficiency, where the blood lacks nutrients needed to aid healing, or there is a lack of blood flow to the area causing further stagnation. If both the Liver and Kidney are weak, ligaments may tear more easily. Dampness or heat in the Liver can increase inflammation in the body, further aggravating any swelling in the knee. Spleen Qi deficiency can cause edema in the lower limbs impairing circulation and blood flow to the area. Practitioners will identify these imbalances and not only treat your pain, but will address any of these underlying problems as well.
If the condition is Bi alone, specific acupuncture points are chosen, in a TCM approach, on meridians that lie on or surround the knee. By needling the areas, Qi and Blood stagnation are removed, thus relieving the pain. A micro-trauma is created, bringing healing factors into the area. Balance Method acupuncture, made popular by the late Dr Richard Tan, is an alternative. Here, the blocked meridians are identified and are treated on a different area of the body. In this case, the elbow will likely be chosen, on the opposite side of the injury. When using this method, it is possible to decrease the pain or even eliminate it in the office. In early sessions, the pain relief is short. With additional treatment, the pain goes away for longer periods. Balance Method acupuncture is particularly useful when patients are in so much pain they do not want acupuncture needles anywhere near their knees. Both styles of acupuncture are equally effective.
Although it is sometimes possible to have a patient recover in one session, a series of acupuncture treatments is often required to encourage complete healing of tissues and alleviation of pain. The number of treatments needed varies depending on the severity of the condition and how long it has been present. In cartilage and ligament tears, surgery can often be prevented, however, with bone-on-bone osteoarthritis, it will likely still be required, though often at a later date than anticipated. For those who do need surgery, acupuncture can improve pain and healing time after knee surgery.
When it comes to assessing acupuncture in the treatment of knee pain in the scientific literature, most published results involve that due to arthritis. In a large study that reviewed a total of 10 trials representing 1456 participants in RCTs using acupuncture for the treatment of the symptoms of osteoarthritis of the knee, it was shown that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee.
We have other tools in TCM as well. At the acute stages of injury, topical liniments such as Zheng Gu Shui ® (Upright Bone Formula) can be used to alleviate pain and speed healing. Aromatic counter-irritants such as Po Sum On®, or White Flower® can relieve pain as well. Moxibustion (moxa), or a TDP lamp which both provide comforting warmth can be used for the treatment of Wind-Cold Bi. Rice-grain sized moxa can be applied to decrease swelling in Bi caused by Wind-Heat-Damp after the initial swelling has subsided. Tui Na (Chinese Massage) is also helpful.
Herbs are also given to alleviate discomfort—For chronic knee pain, a formula based upon Du Huo Ji Sheng Tang (Angelica, pubescentis and taxillus decoction) may be prescribed which can have a positive impact on cartilage integrity. Herbs may be added depending on the patient’s constitution. A meta-analysis has shown that Du Huo Ji Sheng Tang, when combined with sodium hyaluronic acid and given to patients with knee osteoarthritis showed remarkable improvement. It should be noted that the meta-analysis did not review the combination of acupuncture plus the formula, which would likely provide a better result.
For acute knee pain, a formula that has more of an emphasis on moving Qi and Blood may be given such as Shen Tong Zhu Yu Tang (Drive out Blood Stasis from a Painful Body Decoction) with Niu Xi as a guiding herb to direct the formula to the knees. Again, the formula could be modified to suit the particular patient’s needs.
Yan Hu Suo (corydalis root) is a useful addition to any formula as it is a wonderful analgesic.
EFFECTIVENESS IN MY CLINIC: Case Studies
Here are two case studies to demonstrate effectiveness I’ve seen in my clinic:
Case Study 1:
SS, a 32 year old male presented to my clinic with an MRI documented medial meniscus tear. He had been in pain for 8 or 9 years and wanted to avoid surgery. SS led a very active life and tended to aggravate his knee during workouts. He was unable to run, fully extend his leg, or stand up from a sitting position without aggravating his knee. He walked with a limp. I diagnosed him with Wind-Heat-Damp Bi. I gave him one treatment of Balance Acupuncture and his pain was relieved in the office. Pain relief lasted for a few days. After the 6thtreatment, he had “zero pain”, and is not booking the surgery.
Case Study 2:
BV, a 65 year old female presented to my clinic with severe arthritic knee pain for several years. She was unable to walk without pain, and had an altered gait and limp; her knee was swollen and hot. Her affected leg bowed, and she had to walk sideways up and down the stairs. BV was on a lengthy wait list for surgery. I diagnosed her with Wind-Heat-Damp Painful Obstructive Syndrome and treated her with acupuncture, Tui Na, and TDP (heat lamp). Her pain level significantly reduced so that she was able to walk more freely. After her surgery I treated her with acupuncture and she recovered quickly.
In conclusion, knee pain can have various etiologies, from sprained or torn ligaments or tendons, to osteoarthritis. While allopathic medicine addresses the pain with drugs and surgery, which can cause adverse effects, TCM can provide an alternative and safer therapy with acupuncture, moxibustion, Tui Na and herbs.
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