Knee pain in Greenwich

The typical causes of knee pain are related to ageing and injuries like a torn ligament or sprain. Knee problems can also happen due to overuse, perhaps from a job where you repeatedly kneel, such as carpet fitting. If you are overweight, you are also at more risk of knee pain.

Mr Shahid Punwar, consultant orthopaedic surgeon and knee specialist at The Blackheath Hospital, says: “We see two main groups — a younger, sportier group who injure their knees playing football or other sports, and an older group who perhaps have noticed their knees becoming stiffer and swollen over time and develop a form of arthritis.”

Knee pain is challenging to diagnose as more than one problem or injury may be present. Choosing to see a consultant orthopaedic surgeon and knee specialist at Circle Health Group means you get an accurate diagnosis and an opinion fast.

The knee is a complex joint of bones, ligaments, cartilage and tendons. We rely on it for many activities, including kneeling, lifting and climbing stairs.

There are three bones in the knee:

• Shinbone (tibia)
• Thighbone (femur)
• Kneecap (patella)

The tibia and femur are the long leg bones below and above the kneecap.

Your consultant may mention two muscle sets in front of the thigh (the quadriceps) and the back of the thigh (the hamstring muscles). These help you straighten and bend the knee.

Your knee also has three compartments — where the shinbone meets the thighbone (patellofemoral), inside the knee (medial) and outside the knee (lateral femorotibial).

Holding the bones together are four elastic-type ligaments inside and outside your knee: the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL).

The two meniscus cartilages (menisci) on either side of the joint provide shock absorption for the knee as it bends and helps keep it stable. Tendons connect the muscles to the bones. Fluid-filled sacs called bursa cushion the joints and ensure that the knee moves.

Knee pain can often be helped with self-care at home for a few days. You can get rid of knee pain fast by taking the weight off the joint and putting an ice pack or a bag of peas wrapped in a towel on the knee for 15–20 minutes. Repeat the action every two to three hours.

It helps to remember the acronym RICE:

• Rest
• Ice
• Compress
• Elevate

If you take pain relief such as paracetamol, it may also help to stop knee pain.

Is cycling good for knee pain?

Our surgeons recommend cycling and swimming for knee pain.

Cartilage doesn’t heal itself because it doesn’t have enough blood supply — it receives most of its nutrition from the circulation of joint fluid (synovial fluid). Cycling is a low-impact activity can help this and keep the joint moving.

Other options include a rowing machine and exercise classes such as aqua aerobics.

If you can still walk, and the swelling and pain goes in a couple of days, your knee pain is likely to be a minor sprain or injury.

However, if you injure the knee or knee pain stops you from putting weight on the leg and it doesn’t feel stable, you need to seek medical advice urgently. You should see a knee specialist if the pain affects your daily living — for example, if you can’t drive or work reliably or pain wakes you at night.

If you feel a clicking and grinding noise, it’s probably from ‘wear and tear’.

People experience two types of knee pain — pain from injuries and non-injuries.

Knee pain without injury

Inflammatory conditions, wear and tear arthritis, and knee joint infection are all causes of knee pain without injury — also known as non-traumatic causes.

Knee pain with injury

A blow to the knee or falling or twisting can cause your knee to dislocate or fracture. Other common injuries include tearing the meniscus (shock absorber).

The most common causes of knee pain are:

• Arthritis
• Cartilage damage
• Ligament damage
• Patellofemoral pain syndrome
• Patellar tendonitis
• Baker’s cyst
• Bursitis
• Iliotibial band syndrome

Knee arthritis

Early-stage osteoarthritis (OA) and rheumatoid arthritis (RA) are two of the most common causes of knee pain we see at Circle Health Group and The Blackheath Hospital.

OA is a degenerative condition more likely to happen in the over-50s. It can start with a sharp pain when you move the knee and worsens as the cartilage gradually wears away.

RA is an autoimmune condition causing acute knee joint inflammation and can affect younger people than those affected by OA. New medical treatments have decreased the number of people suffering from RA.

Cartilage damage

Acute and chronic injuries to the cartilage, particularly a torn meniscus, can happen with sprains. You might be told to strap or brace the knee to avoid injuring it further, or you could need surgery to repair it.

Ligament damage

Mr Punwar explains, “There are two cruciate ligaments. The anterior ligament stops the shinbone from going forward, and the posterior ligament (PCL) stops it from going back. The most common ligament that is injured is the anterior one.”

If you damage your ACL, you’ll feel a pop and often there is a shock absorber tear as well. The knee can give way as you walk and swells up. If it doesn’t settle after rest, ice and elevation, you should see a knee specialist, as these injuries are often overlooked and can be harder to repair the longer you leave it.

Patellofemoral pain syndrome

At The Blackheath Hospital, we see teenagers of 16 and over and young adults with patellofemoral pain syndrome, also known as anterior knee pain. This is made worse by going up and down stairs or squatting. The knee may feel stiff or give way.

Patellar tendonitis

The tendons around the kneecap (patella) can become sore and inflamed when you overuse them. Patella tendonitis can also happen when you hit the ground hard while jumping or running in sports such as tennis and netball.

Baker’s cyst

Another common pain behind the knee in adults is a Baker’s cyst, also called a popliteal cyst. It’s caused by joint fluid collecting at the back of the knee and can be due to a meniscus tear or an irritated bursa. It can also happen in conjunction with an arthritic knee.

Bursitis

Bursae are fluid-filled spaces between the bone and soft tissue. In the knee, the prepatellar bursa, which is over the kneecap, can ache if you kneel a lot — for example, when gardening.

Iliotibial band syndrome

We sometimes see patients at The Blackheath Hospital with Iliotibial band syndrome (ITB) if they have overused their knee, which causes burning, aching pain on the outer knee joint. The iliotibial band is the fibres on the outside of the thigh.

Your symptoms, the knee pain’s location, age and medical history, and a physical examination and diagnostic tests can help your orthopaedic consultant diagnose the condition causing the pain.

The questions your knee specialist might ask include:

• When your knee pain started
• Where it hurts
• Whether one or both knees are painful
• Whether the pain is worse at night or rest
• How quickly the pain happened
• Whether you injured it

Your age may be a factor. If you are over 50, the likely conditions include osteoarthritis, gout, degenerative meniscal tear and a Baker’s cyst.

Young adults are more likely to have patellofemoral pain (patellofemoral means under the kneecap) or trauma from cruciate and other ligament sprains. Children can also have patellofemoral pain and growing pains as well as knee cap instability.

The site of your knee pain and the knee’s stability will help your consultant decide the most likely underlying condition and what treatment options are suitable for you.

Some medical issues, like osteoarthritis, can trigger pain in several areas, such as the outer and inner parts of the knee and under the kneecap. An injury or blow can affect specific ligaments, cartilages, or tendons.

Mr Punwar said: “We often ask patients to point to the pain with one finger. Then we’ll look closely at that area on X-rays and scans, guiding certain treatments.”

Back of knee pain (posterior)

Pain behind the knee, also known as posterior knee pain, may result from wear and tear (osteoarthritis or rheumatoid arthritis), a blow causing a posterior cruciate ligament tear or a Baker’s cyst. It may also be muscle strain.

Inside knee pain (medial)

Medial means ‘close to the midline of the body’. One of the most common reasons for pain on the inside part of the knee is damage to the shock absorber (menisci) or medial collateral ligament (MCL) from a blow to the outside of the knee.

Pain on the outside of the knee (lateral)

Lateral means ‘away from the midline of the body’. Pain on the knee’s outer side is called lateral knee pain (LKP). Typical causes of LKP are sports injuries, such as running or skiing, and overuse.

Pain in the front of the knee (anterior)

Anterior means ‘nearer the front’. Rapid swelling following an injury, such as a sudden stop or twist, can cause a rupture of the anterior cruciate ligament (ACL). The ACL is damaged more often than other knee ligaments.

Pain under the kneecap (patellofemoral joint)

Mr Punwar said: “If it hurts around the kneecap at the front, then it may be a small amount of cartilage-wear underneath the kneecap. It will hurt when you sit or kneel for long periods, and then when you get up, the knee clicks.”

Patella tendonitis could also be the culprit if the pain is between your kneecap and the shin.

Referred knee pain from the hip

Sometimes, knee pain may be a result of a problem in the hip.

Mr Punwar explains: “With knee pain, it’s important to examine the hip because there’s a fairly large percentage of referred pain. You can have a stiff arthritic hip and feel the pain exclusively in your knee. A thorough examination and history are key to treating your knee pain.”

Several knee surgeons at The Blackheath, including Mr Punwar, are skilled at first-time (primary) hip replacements, so you won’t need to be referred to another specialist if the hip is the cause of your knee pain.

The Blackheath Hospital’s imaging centre has a range of imaging equipment to aid your consultant’s diagnosis, including X-ray and magnetic resonance imaging (MRI).

Mr Punwar said: “X-ray is helpful for arthritis to find any loss of joint space between the bones and extra bits of bone on the sides. If we don’t see anything from the X-ray (and in a younger group, we wouldn’t expect arthritis), we do an MRI scan. MRI tells us about soft tissue in the knee and whether the menisci or the ligaments are torn.”

Once the X-ray or MRI has come back, your knee specialist will have a picture of the problem, which will help them decide on the best way forward.

It might be a straightforward decision to proceed with a knee arthroscopy (keyhole surgery). This would be decided, for example, if a ligament has been torn, a meniscus has ruptured acutely, or there’s a displaced fragment. The surgeon will examine the joint with a tiny camera and try to repair it.

But Mr Punwar says, “We will always try to go down the non-operative route in the first instance because we are always weighing up the risks and benefits and do not want to operate if the risk of surgery is slightly worse than the benefit.”

The Blackheath Hospital has plenty of equipment and expertise. Our orthopaedic surgeons, including knee specialists, meet regularly to discuss their outcomes and share best practices.

Mr Punwar explains, “It’s important to move with the times, but we also like to use established techniques with a good track record that have a proven benefit. So, you get a solid, trusted opinion and techniques with good research behind them. The knee implants we use have excellent longevity data on the National Joint Registry.

He goes on to say, “We are all members of specialist societies like the British Association of Knee Surgeons and discuss knee implants and other advances to keep up to date. We also have plans to innovate at The Blackheath. For example, we are looking into buying a MAKO robot arm from another part of Circle Health Group to use for knee replacement surgery.”

If the X-ray shows arthritis in the knee, you might be offered a knee replacement.

Mr Punwar says, “We tend not to do arthroscopy, washouts and debridement for arthritis anymore. It’s no longer recommended because it doesn’t change the underlying problem, and people often go on to knee replacement surgery anyway.”

However, it may be appropriate in selected cases depending on ‘functional activity’ like tennis. The thinking is that you’re better off with as much of your knee as possible if you want to continue playing. So, the consultant removing loose cartilage with a keyhole operation might help.

For patients with knee arthritis, Mr Punwar recommends physiotherapy and gentle non-impact cyclical movement. He says, “If you can keep running, you should. Some find they can cycle or use a rowing machine and swim but running starts to give them more pain. I say do what you can do. If you’re keen to continue with sports with a twisting movement, like football, we can try injections.”

Steroid injections for knee pain

A steroid injection numbs your knee for the day and calms inflammation. It is the most reliable injection — however, you are still masking the pain rather than treating it.

If there’s much fluid on the knee, the consultant may remove it before injecting the steroid.

Steroid injections are reasonable if you travel in the next few days or have an event like a wedding coming up where you want to remain mobile and pain-free.

Braces for knee pain

Rest for a week, ice and elevation are important with a sudden injury to help the swelling go down. Excessive rest can be harmful. Your doctor will be able to advise you.

If it doesn’t settle, that’s when you need to have it checked.

Mr Punwar said: “Braces are becoming more popular because they are lower profile and designed for arthritis. You can sometimes get a knee back to correct alignment with a brace. It’s not a long-term treatment. Knee supports can also be helpful, even if it’s psychological, but it is just compressing the knee and giving it some stability.”

Weight management and nutrition

Another way to deal with knee pain that doesn’t involve surgery is to lose weight and improve your nutrition.

If the diagnosis is arthritis, it’s most likely that your knee specialist will recommend physiotherapy and injections.

Knee replacements are common for end-stage wear and tear arthritis when unremitting gnawing pain keeps you up at night. Our consultants will try to minimise muscle damage and use advanced recovery techniques to reduce pain and swelling and immediately get you up and about.

If the arthritis is in one part of the knee, your consultant may suggest a partial knee replacement. No ligaments are taken away, so you can still twist and bend like a normal knee.

In younger groups, if you have torn a ligament or meniscus, the decision is more likely to be arthroscopic surgery or an ACL reconstruction, which we do a lot at The Blackheath Hospital.

How long does the pain last after a knee replacement?

Recovery is approximately six weeks and the knee can be acutely painful for two weeks while it heals, but it gets better each day. You’ll be given painkillers and ice packs. Acute pain settles quicker with a partial knee replacement.

If you’re worried about knee pain that isn’t getting better, speak to one of our knee pain specialists for assessment and treatment.

You can book a private consultation online today or call 020 8318 7722 to speak with one of our friendly team members here at The Blackheath Hospital.