Describes the pathogenesis and management of knee pain.

1. KNEE PAIN; DIAGNOSIS &
MANAGEMENT
[Injection Therapy]
Col Tariq H. Khan

4. Nerve Supply of the Knee Joints

6. Differential Diagnosis
• Patellofemoral syndrome
• Iliotibial band syndrome
• Patellar tendonitis
• Anserine bursitis
• Meniscus tear
• Collateral ligament tear-medial or lateral
• Cruciate ligament tear-Anterior or
posterior
• Osgood Schlatter
• Osteochondritis-dessicans
• Neuropathic arthropathy
• Charcoal joint
• Tumor (Osteosarcoma)
• Referred pain (hip = avascular
necrosis)
• Prepatellar bursitis
• Baker’s cyst
• Septic joint; gonococcal
• Arthritis
• Osteoarthritis
• Rheumatoid
• Gout
• Septic
• Pseudogout
• Reactive arthritis (Reiters)
• Medial Plica syndrome
• Referred pain from back
• Sciatica
• Fracture

7. Diagnosis
• History
• General physical examination
• Joint examination
• Routine Laboratory examination
• Radiography
• X-rays
• CT scan / MRI
• Arthrograms / Arthroscopy

8. History
• Time Course
• Mechanism of injury
• Pain characteristics
• Mechanical symptoms
• Effusion
• Medical History

9. The Swollen Knee
•Acute pain & swelling:
• Most commonly: trauma, infection,
or crystalline disease
• Rarely: RA, seronegative, SpAs
•Chronic pain & swelling:
• Autoimmune disorders (e.g. RA,
ApA), infection, sarcoidosis, foreign
body synovitis, avascular necrosis,
sickle cell, hemophilia, tumor,
Charcot joint, PVNS

12. Radiography

15. • (4) Chondrogenic in knee OA:
• Arthroscopically, positive clinical and chondrogenic effects were seen after
prolotherapy with hypertonic dextrose injection in participants with
symptomatic grade IV KOA, suggesting disease-modifying effects.
• PM R. 2016 Nov;8(11):1072-1082.
https://www.ncbi.nlm.nih.gov/pubmed/27058744
• [human, randomized controlled trials, N>50]
• For the long term, DX seems to be more advantageous, while the two
treatments were comparable in the short term. Because of the satisfactory
pain relief and restoring of function, we would prefer DX prolotherapy for
the treatment of patients with OA.
• J Orthop Sci. 2014 Sep;19(5):737-43.
https://www.ncbi.nlm.nih.gov/pubmed/25158896

16. • In chronic nonspecific low-back pain, significant and sustained
reductions in pain and disability occur with ligament injections,
IRRESPECTIVE (do you know why?) of the solution injected or the
concurrent use of exercises.
• Spine (Phila Pa 1976). 2004 Jan 1;29(1):9-16
https://www.ncbi.nlm.nih.gov/pubmed/14699269

17. Backer cyst
• Backer cyst especially complicated with septa and synovial thickening
and hypertrophy and multiple internal echoes ,my technique is to
start with one shot of steroid after long axis US guided aspiration
followed by weekly injection with Methotrexate 25 mg in 10 cc
normal saline for six weeks with good results and decrease of
recurrence

18. Treatment options
• Conservative
• Physical therapy; heat and cold
• exercise, and weight loss
• Nonprescription pain relievers such as acetaminophen (Paracetamol), aspirin,
ibuprofen (Brufen®), and naproxen (Naprox®)
• Prescription medicines like Celebrex®

19. OTC Products
• Chondroitin
Sulphate
• Glucosamine

20. Interventional Pain Management
• Synovial fluid aspiration
• Intra-articular steroid injection
• Intra-lesional steroid injection
• Intra-articular PRP injection(coming soon)
• Intra-lesional PRP injection(coming soon)
• Intra-articular Ozone injection
• Hyaluronic acid injection
• Genzyme injection

21. Steroid injections
• Dexamethason (Decadron®)
• Hydrocortisone (Solucortef®)
• Triamcinolone acetonide (Kenacoert®)
• Methylprednisolone (Depot-medrol®)

22. Complications of Steroids
• Noninfectious
• Tendon rupture
• nerve atrophy or necrosis
• skin atrophy, vitiligo
• dystrophic calcification around joint capsule
• steroid toxicity
• osteoporosis,
• menstrual irregularity,
• ecchymoses, and/or
• accelerated cataract formation.
• suppression of the hypothalamic-pituitary axis
• increase in blood glucose levels,
• osteonecrosis, in 0.1-3% of cases.

23. Complications of Steroids
• Infectious
• iatrogenic septic arthritis in 1 per 2000-15,000 injections
• immediate repeat arthrocentesis
• institution of an antibiotic regimen
• arthrotomy or arthroscopy

24. Platelet-rich plasma
• higher-than-normal levels of cytokines and growth factors,
• platelet-derived growth factor (PDGF),
• insulin like growth factors (IGFs) 1 and 2,
• interleukin (IL)-8,
• keratinocyte growth factor (KGF),
• epidermal growth factor (EGF),
• connective tissue growth factor (CTGF),
• fibroblast growth factor (FGF), and
• transforming growth factor (TGF)

25. Platelet-rich plasma
• Arthrex ACP and the Biomet GPS III.
• 3-5 mL per injection, with a series of three injections performed

26. Stem Cell Therapy

27. Intraarticular Approaches
1. Lateral superopatellar
2. Medial superopatellar
3. Lateral midpatellar
4. Medial midpatellar
5. Lateral inferopatellar
6. Medial inferopatellar

28. Positions for injections
• Supine with flexed knee
• Sitting

29. Viscoelastic Supplementation

30. Exercises

31. Next Frontiers
• Radiofrequency ablation of genicular nerves
• Arthroscopy
• Knee joint replacement

32. Conclusion
• Knee pain is a debilitating thing
• It effects the quality of life of the sufferers
• Knee pain needs to be assessed and treated by all means available to
us.