Pain Inside Knee; Fascia at the Heart of it All
Fascia. While I described this tissue briefly in the anatomy section of this article, a mere brief description really can’t describe just how important this tissue is for pretty much everything that your body does, including pain inside knee.
There are some that think that all your fascia is there for is to act as a barrier for infection. Pretty basic and some put for a pretty good argument for this belief.
Until…you start to look at how many receptors are embedded in your fascia. Receptors with names like Golgi tendon organs (GTOs), Pacini corpuscles, Ruffini corpuscles and interstitial receptors. Recent research has also found receptors for endocannabinoids in the fascia—leaving some very interesting questions for discussion about how cannabis / CBD may play a role in pain.
If you follow the ridiculous assumption that the fascia just acts as a barrier, then you can assume that the computer you are reading this on uses the motherboard as a dust cover for the red and green wires.
Why would the human body have a stunning number of receptors built into the fascia if this organ wasn’t critical for movement?
Now that that’s out of the way, we can move on to some more relevant stuff.
The fascia plays several roles. One role is to affect movements of joints. I know that you probably thought (up until now…) that muscles move joints. Most likely not. Rather, muscles increase the tension in the fascia and the fascia is actually what moves a joint. Quite a shift from what we’ve thought for pretty much forever.
The next role for the fascia is that it acts as a very serious source of feedback on movement. Every single movement in your body is orchestrated by the most amazing serious of receptors, measuring every micrometer of movement, every change in pressure and every change in speed.
This all works fine and dandy until we get an injury. It could be something as minor as bumping your thigh on a railing or as severe as a knee replacement surgery. Maybe you rested the area or, worse, took 800 mg ibuprofen to control the inflammation until the knee felt better.
This injury, especially if it happens in an area of the fascia that it particularly dense in these receptors, can create some serious problems. Research has shown that an injured area of the fascia can quickly become hypoxic (runs out of oxygen) and the normal fluidity of the fascia becomes stiff and thick. The Fascial Manipulation people call this area a “densification.”
Two things happen from here. First, if the densification occurs in a region of the fascia with a high density of receptors, the feedback from this region will be disrupted. Considering that these receptors are critical for proper control of movement, you can see just how much of a problem this could be.
Second, the fascia in that region will no longer stretch and move the way it is supposed to. Since healthy fascial movement is critical for joints to function properly, this will lead to uneven force on a joint, causing pain and, if allowed to happen long enough, joint degeneration.
Pain Inside Knee; Treating Your Fascia
Now that you understand just how important the fascia is to a healthy functioning joint (knee or elsewhere), what do you do if you have knee pain?
There are providers out there who are quite competent at treating the fascia, but you’re going to have to do your homework. The average chiropractor, massage therapist or physical therapist is not very good at treating fascia.
This means you’ll have to do your homework. And here’s a good resource list to get started (somewhat in the order that I feel is best):
- Fascial Manipulation providers
- Graston Technique providers
- Active Release Technique or Neuromuscular Re-Education providers
- IASTM, ASTYM or SASTM providers (typically physical therapists and athletic trainers)
- Rolfing therapists
- Massage therapist with specialized training in deep tissue / fascial work
By now means is this an exhaustive list and my biases are built in, but this should give you a very good head start on finding a provider to help you.
If you’re curious as to what treatment of the knee is like using soft tissue techniques, you can check out my YouTube video on this topic here.
In the next section, I’ll cover some other tools that can be used to further help manage any pain inside knee you may have.
Exercise for Pain Inside Knee
I’ve just covered what I feel is required for pretty much every knee condition—provider intervention by someone who understands how to treat the soft tissues of the knee. Maybe it’s a little self-serving, but I do believe that almost everyone with knee pain will benefit from at least a single treatment to help balance the muscles, ligaments, tendons and fascia surrounding this important joint.
However, I am willing to accept that there is a stubborn group of patients out there who are determined to manage their knee pain without any help from anyone. This next section is for you.
Oh. And anyone living in the Antarctic and in the caves with the Taliban who don’t have access to a decent provider.
Exercise for Pain Inside Knee
Move. Few things are as good for any joint in your body as movement. Your joint surfaces do not have their own blood supply. They essentially sit in a small pool of nutrients that is fed by small arteries.
I explain this setup like a sponge sitting in a pond. You can look at the sponge sitting there as long as you’d like to stare, but until you start stepping on and off the sponge you won’t get fluid exchange in the sponge.
Start stepping on it and you get waste products squished out and new nutrients sucked back in.
Our joints are the same way with movements. Start moving and the joint surfaces get nutrition in and waste products out. Live life as a couch potato and your joints will suffer.
(As a side note—those small blood vessels that feed the joints can become clogged (atherosclerosis) if you have a pro-heart disease lifestyle. This is why there are strong links between heart disease and arthritis. It’s beyond the scope of this article to go into how to avoid heart disease with lifestyle, but you can check out my eBook from the Modern Health Myths’ eBook page.)
Unfortunately for many suffering from pain inside knee, activity is usually the first thing to go. Less exercise will lead to more problems, feeding into the vicious circle of knee pain. You can check out my short video on exercise for knee pain by clicking here.
For the big picture, staying active is critical for good knee health. Hiking, dancing, running, resistance training or bike riding are all activities that will strengthen your knees and derail long-term problems.
There are certainly knee-specific exercises that will help your knee pain. These can range from simple knee extensions using elastic tubing to all-out proprioceptive exercises on a balance board while making soufflé and reciting every other letter of the alphabet backwards.
If you are self-motivated then YouTube is a great resource to get started with. If you need more motivation than finding a provider who can guide you through the rehab exercises is going to be a better idea.
Using a Vibration Exercise Machine for Pain Inside Knee
The stronger the muscles of your knee are, the better it is going to feel. I experience this personally; in the summers, only crazy people and kangaroo rats go hiking here in Arizona. I’ve noticed that in the winter during hiking season, my knee that I had a meniscectomy on in 1998 (back when I didn’t know any better) gives me less problems.
Many knee pain sufferers get caught in a catch-22. Exercise can benefit the knee arthritis, but the knee is too painful to exercise. So they sit, with the knee slowly getting worse over time.
Luckily, there is a solution.
Our office has used a vibration exercise machine for almost 10 years now and the results, when used appropriately, are quite dramatic. But, up until know, this response in our office has been largely anecdotal without much research to support its use.
But no longer.
Researchers studied the use of a vibration exercise machine on inflammation and knee pain in a group of elderly patients with pain inside knee from arthritis. The treatment was very simple: knee squat exercises on a vibration exercise platform 3 times a week for 3 months.
The benefits of knee rehab exercises on a vibration platform were greater than the same exercises without vibration:
- Inflammation was lower in the vibration group (as measured by sTNFR1 and sTNFR2)
- Self-reported pain was lower in the whole body vibration group
- There was an increase in balance in the vibration group
- Speed and distance walked improved again in the vibration group
The beauty of using whole body vibration for pain inside knee is that the squats can be very shallow. With knee pain, you’re probably aware that the deeper the squat the more the pain. Imagine if you can exercise the knee and do your squats with hardly any bend in the knee at all.
This is the advantage with vibration plate exercises.
Effectiveness of Natural Approaches for Pain Inside Knee
Many people consider a diagnosis of arthritis knee pain as a lifetime of future suffering, or at least until a knee replacement can be done. Pretty depressing way to look at it.
This is a perception that many patients have, possibly because primary care doctors and orthopedic specialists don’t understand that there are many tools to use besides drugs, injections and surgery.
Just like every other condition that the human body can experience, the path to fix or manage said condition involves a multi-factorial approach, not a single one.
Treatment for pain inside knee is no exception.
I’ve already pointed out how important it is to find a provider who can address the soft tissues surrounding the knee. I’ve pointed out how critical exercise is for healthy knees. In a few I’ll cover other approaches beyond these two for helping with pain inside knee.
Before we go any further, I need to point out that these approaches really do work.
In one study, researchers looked at what patients who had been diagnosed with pain inside knee from arthritis changed to help improve symptoms.
Here’s what they found:
- 75% increased activity levels (80% of them felt starting exercise was helpful)
- 33% tried acupuncture, orthotics and/or braces (75% of them felt adding these tools was helpful)
- 52% of participants started analgesic therapy (they must not have read Part 1 of this article…)
- 36% started supplements (50% of them felt that glucosamine or glucosamine/chondroitin was helpful—more on this later)
For me, the message is that taking control of your treatment for pain inside your knee from arthritis can have some pretty cool payoffs. And this is without any type of provider treatments or even knee-focused exercises. Just think how much better the outcomes could be with a solid, comprehensive approach.
Supplements for Pain Inside Knee
In Part one of this article, I covered why prescription and over the counter analgesics are a pretty bad idea for knee pain (or any other musculoskeletal problem, for that matter).
With the standard go-to drugs for pain inside knee what is society supposed to pop in their collective mouths to control pain?
Luckily, there are some answers.
Glucosamine for Pain Inside Knee
The idea of using natural approaches for knee pain has been around for quite some time. Glucosamine began to hit the scenes when I was still in school.
If I remember correctly, the first clinical trial (while I was in chiropractic school) was on a brontosaurus.
Sure, weight loss would’ve helped and the vegetarian diet was anti-inflammatory, but the real problem was getting them into the MRI scanner for the imaging…
(For the paleontology geeks out there, I am aware that the brontosaurus has been renamed the Apatosaurus…)
Quite frankly, the research on glucosamine over the years has been a blend of “OK” and negative. I’ve got several theories about why this was the case:
- Many patients put into trials do not have knee pain caused by arthritis. I pointed out quite clearly in Part one that in many cases of pain inside knee, the soft tissues surrounding the knee are the culprit. Glucosamine is not going to help if the soft tissues are what is causing your knee pain.
- Higher quality glucosamine used in the studies was not used.
- The study length was not sufficient. Following up for 6 months is not likely to show much of a difference versus a study that lasts years.
For a real idea of how glucosamine supplements can help with knee pain, savvy researchers in one research study looked at the benefits of glucosamine for pain inside knee in a different manner than previous studies.
Six hundred patients with pain inside knee from arthritis were followed for 2 years. They were asked if they were taking prescriptions (anti-inflammatory drugs, analgesics) and/or a glucosamine/chondroitin supplement.
Here’s where the researchers got creative. They looked for any loss of joint space width and volume of the cartilage to see if it was affected by what participants were taking. Here’s what they found:
- Those who were taking the glucosamine / chondroitin lost less cartilage volume after 2 years regardless of whether or not they were also taking pain medications and/or anti-inflammatories.
These results have been reproduced in other studies. Notably, the benefits on protecting the cartilage seem to be better when taken before the degeneration is more advanced.
In other words, start early. And make sure you stick with higher quality products.
Sunshine for Pain Inside Knee
Just in case you missed the window for early use of glucosamine for pain inside knee and your knee (or knees) in general has not aged gracefully, there may a simple, inexpensive and safe solution that you can add today to delay any further progression of the arthritis.
Researchers studied 418 participants who had at least one knee with both symptoms of arthritis knee pain and signs of arthritis on X-ray.
Vitamin D and parathyroid hormone (PTH-a hormone that works with vitamin D to keep calcium levels in the blood stable) blood levels were monitored over the course of 4 years and compared to the amount of progression of his or her knee osteoarthritis.
Here’s what they found:
- As has been seen in almost every other study on vitamin D, levels were at the very low end of normal (26.2 μg/L) and a 16% were deficient (below 15 μg/L).
- Those with vitamin D levels below 15 had double the risk of knee osteoarthritis progression.
- Even worse, if someone had both low vitamin D and high PTH there was a 320% higher risk of arthritis progressing.
This does not mean that you can start sipping on liquid vitamin D at 10,000 IU per day and sit on your duff watching football, confident that your knee pain is going away by tomorrow.
But this does add vitamin D to the list of things that you should add for arthritis knee pain relief.
Dosages can vary based on your individual circumstances. If you’re not sure how much you should take, I suggest you watch my short FAQ video on vitamin D that can be found by clicking here.
Omega-3 Fatty Acids for Resolving Pain Inside Knee
In part one of this article I made it clear how I feel about the long-term dangers of using anti-inflammatories for almost any kind of musculoskeletal pain. Just in case you thought I was off my rocker and, just to spite me, you’ve been taking 2400 mg ibuprofen since the day you read part one, let’s look at this anti-inflammatory thing from a different viewpoint.
The process of inflammation is a natural one. Inflammation serves several purposes.
One key purpose is the prevention and management of infections. Your immune system (the system responsible for the inflammatory response) gears up to fight off an invader, and, should that invader break through, it will gear up an attack on that invader, be it a virus, bacteria, yeast or even a tumor cell.
Another key purpose of inflammation is the clearing out of damaged tissue and subsequent repair of the damaged region.
Each of these actions of the immune system needs balance and control:
- Too much protection against an invader and you get allergies and asthma.
- Too strong of a reaction against an invader and you could go into shock.
- Too strong of a response to an injury and undamaged tissue gets taken out in the process.
Controlling the very early stages of inflammation is a good thing (maybe the first 24 hours or so). But can our society’s obsession with anti-inflammatories be affecting the natural history of this process? You bet!
Consider inflammation as pushing a boulder uphill. Once you get it over the top, the going’s easy from there. Anti-inflammatories may, in the initial stages, make the hill you must push the boulder over smaller.
But the initial stages of inflammation are supposed to end–after a few days with an infection (hopefully) and within 24 hours with an injury (depending on severity of the injury).
Medicine used to think that inflammation, once started, would resolve all on its own, but we now know this is not true.
The resolution of inflammation is not a passive process. The body has to actively end inflammation. And there are some critical factors needed for this process.
Namely, DHA and EPA, the omega-3 fats from fish oils.
DHA and EPA are required to make a class of compounds referred to as Resolvins and Protectins (I know, maybe not the most clever names…).
If you’re a biochemistry nerd, you can read more about them in this particular review.
If you want to do everything you can on your journey to provide arthritis knee pain relief, then paying attention to the fats you take in is an important tool. You can do this by:
- Increasing your intake of healthy fats found in wild caught fish and game, fully grass-fed beef, olive oils, raw nuts, seeds, certain grains (salba, quinoa as examples) and avocados.
- Decreasing your intake of unhealthy fats found in hydrogenated oils and animal-based saturated fats. The main source of saturated fats are fats contained in our society’s poorly raised livestock.
- Decreasing your intake of omega 6 fatty acids. These are found in certain oils like corn, sunflower, soybean and peanut oils.
- Consider supplementing UP TO 3 full grams of omega-3 per day (NOT 3 capsules per day—3 grams per day). You can check out my video on fish oils by clicking here.
Ironically, anti-inflammatories slowed or stopped the ability of EPA and DHA to halt inflammation (with the exception of aspirin, which may help the process).
So, next time you think about curbing inflammation with drugs, shift your thinking. Think about how you are going to RESOLVE your inflammation instead.
Omega-3 Fatty Acids for Protecting Against Pain Inside Knee from the Meniscus
As I just pointed out, the right types of fats can help to control and resolve inflammation to curb pain and inflammation that can damage your knees in the long run.
But can the right types of fat in your diet also protect your joints in the first place?
That just what researchers asked in a study looking at the ability of different types of fats (specifically saturated fats, omega 3 and omega 6 fatty acids) to protect against damage to the medial meniscus of the knees of mice.
Not surprisingly, saturated fats and omega 6 fatty acids did not protect against the development of arthritis. Worse, these fats increased the amount of arthritis that resulted, increased extra bone formation around the knee (a hallmark of arthritis) and increased scar formation after an injury.
Let me put this more plainly: The dietary choices you make WILL absolutely increase the damage to your joints that occurs with an injury, leading to more arthritis in every one of your joints years later.
Omega 3 fatty acids were a different story.
The omega 3 fatty acids improved wound repair as well as lowered the risk of developing arthritis.
Never doubt the power that diet and supplements can play in your long-term health.
Arthritis is NOT something that has to happen to your joints. Think about that the next time you reach for that bag of chips…
A Quick Note about Fish Oil Supplementation
As with anything, you get what you pay for. Lower quality, less expensive brands are more likely to have contaminants.
Just in case you think inexpensive brands are just as good as the expensive brands, recall when the New York Attorney General charged Target, GNC, Walmart and Walgreens with removing certain supplements from the shelves because quality testing demonstrated that these supplements either did not contain the labeled ingredient or contained ingredients not listed on the bottle.
While this action by the New York Attorney General was related to a short list of supplements, it is likely that this quality control issue cuts across many other supplements that you can buy at non-physician outlets. This problem is probably greater at retail outlets that do not focus on supplements, although the inclusion of GNC into the cease and desist order certainly questions GNC’s overall quality control process.
When it comes to fish oil supplements, the contamination with polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCs) is of concern. The higher quality supplement companies will go through expensive and time consuming molecular distillation procedures to make sure that their fish oil supplements will be free from these contaminants.
But really—if these higher quality supplements cost more (sometimes twice as much), is it really a big deal if there’s a few extra “treats” in the fish oils?
Contaminated fish oils were shown in an animal study to lower cardiovascular disease risk factors, the contaminants led to damage to fats (lipid peroxidation) and loss of antioxidant reserves. These changes can actually do far more damage to your body in the long run.
As a physician who sells physician-level supplements in my office, this article may seem a little self-serving, but this study should certainly give you some food for thought when it comes to buying your fish oil supplements with a focus on cost rather than quality. Always make sure that you are buying supplements that have the quality control aspects either on the bottle or readily available on the manufacturer’s website.
If your health really does matter, it pays to make sure you get good quality for your money and not just finding the cheapest fish oil you can find. Just in case you don’t have access to a physician who sells higher quality fish oil supplements, Nordic Naturals is a brand that can be found at many health food stores or online at Amazon.
Other Tools to Help Pain Inside Knee
Now that I’ve covered three of the most important things to do for arthritis knee pain relief (soft-tissue based treatments, exercise and diet/supplements), I’m going to end with some other approaches that have been shown to help with pain inside knee.
A TENS Unit for Pain Inside Knee
A Transcutaneous Electrical Nerve Stimulator (or TENS for short) is a simple device that uses a 9-volt battery to send an electrical wave to block pain from making it to the spinal cord and your brain. I use the analogy of rubbing your elbow or head after you bang it on something. The advantage with a TENS unit is that the stimulation can last for much longer.
There is not really a down side to using a TENS unit. They are safe (so long as you don’t use them over your pacemaker or crank them up high enough to cause a burn…), non-drug and can provide a good degree of pain relief.
This is likely what prompted researchers to look at a TENS unit to help provide arthritis knee pain relief. It was compared to hyaluronic acid injections into the knee (more on this in a bit).
The TENS unit was used for 20 minutes, 3 times per week for 4 weeks while the injections were given once per week for 5 weeks. The TENS led to greater improvements in pain at 6 weeks as well as at 3 months.
I found it interesting that the use of a TENS unit had long-lasting effects because TENS units are generally considered to only manage pain. They don’t affect healing or inflammation.
It is entirely possible that the study participants felt better in the short-term using the TENS unit and, as a result, became more active than the injection group. Since exercise and activity are well-known to help with arthritis knee pain relief, this makes sense.
It also makes sense to ask your doctor to prescribe a TENS unit or look into getting one yourself (there are some links to products on the product review blog linked to above).
Weight Loss for Pain Inside Knee
It will probably come as no surprise to you if I mentioned that weight loss will help with pain inside knee. Common sense will tell you that, with every additional pound that you carry around your knees are taking a huge chunk of the extra stress.
Any good surgeon will refuse to operate on your knees until you are closer to an ideal body weight. This will help to improve the outcomes of any surgery.
I know, I know. Losing weight is the GOAL, not the process, and too many physicians leave it at that.
Like people who are overweight don’t know that weight loss will help their knees??
This is why our office has several programs in place to help meet your weight loss goals IF you are truly motivated to lose weight. You can read about our in-office weight loss programs by clicking here (these are also available remotely for those who do not live near the office).
Just in case you aren’t convinced that weight plays a critical role in pain inside knee, in this study researchers followed 250 adults with no knee arthritis for 2 years. MRIs were done before and after to monitor the effect of weight loss or gain on the height of the cartilage and pain inside knee. Here’s what they found:
- In the 18% who were found to have medial meniscal tears, for every 1% gain in weight, there was a 0.2% increased loss of cartilage volume and 11.6% increase in pain.
The cartilage volume changes were not great, but the changes in pain levels with even a very small weight change was quite dramatic. This may be related to increasing overall inflammation with weight gain. More inflammation means more pain.
Hyaluaronic Acid Injections for Arthritis Knee Pain Relief
I remember the first time a patient came into my office asking about using hyaluronic acid injections for arthritis knee pain relief (Sandy–if you’re reading this I’m talking about you…). This was probably 15 years ago and she had to order the hyaluronic acid through the mail for her orthopedic doctor to inject it.
Luckily, the familiarity of most doctors with these types of injections into the knee has increased and most don’t have to go through major hassles to have it done.
The procedure involves injecting hyaluronic acid, or some version of it, into the knee joint. Hyaluronic acid contains the building blocks of cartilage, so it makes at least some sense that this might be a good idea.
The results over the years seems to have been okay. Not stellar, but okay. With one exception (a patient who developed an infection in the joint after the injection–but this was a technique problem and not a problem with the treatment), I have not seen any downsides to this. Some seem to respond, some don’t.
I’m sure as medicine continues to explore this type of approach, I’m sure the outcomes will continue to improve.
There are several hyaluronic acid products on the market and it can be hard to tell if one is better than another. But, in a research study, researchers compared how will the low-molecular weight injections compared to the intermediate-weight injections.
Hyalgan has been one of the main hyaluronic acid products available almost since the beginning and is considered a low molecular weight product.
The pain reduction was better with the intermediate weight product. While the difference was not great, it was enough to suggest that the heavier-weight products are a better option for pain control and certainly adds to the total picture of how this approach can add to arthritis knee pain relief.
Other Types of Injections for Pain Inside Knee
There are several other types of injections that are available beyond the typical steroid shot for knee pain (which I do not recommend at all for reasons I covered in Part 1 of this article).
While I love to tie approaches for knee pain to research studies, this next section will not contain any references and is based mainly on my experience with patients in my office.
Prolotherapy for Pain Inside Knee
Prolotherapy is the use of some type of irritating solution (such as dextrose) into the soft tissues surrounding a joint. This is designed to irritate the tissues to stimulate a healing response.
Given that this is the same concept with many of the soft tissue techniques I mentioned at the beginning of this article, I’m a fan of this type of approach.
The advantage with prolotherapy is that, with a needle, your provider can treat tissues that are far too deep to treat with a non-invasive approach.
The type of provider that can perform prolotherapy for pain inside knee depends upon where you live. It may be an orthopedic doctor, naturopathic doctor, physician’s assistant or nurse practitioner.
Platelet Rich Plasma (PRP) for Pain Inside Knee
PRP is a method of extracting platelets from your blood and spinning them down in a centrifuge. The platelets are then injected back into the knee (or other body part) with the goal of stimulating the tissues to heal.
Some providers will use additional mixtures into the platelets to further stimulate healing, but the jury’s still out on whether or not this is more effective.
Overall, the current research on PRP for pain inside knee has been positive. As the research continues to progress I do believe that PRP is going to be a strong player in managing arthritis knee pain relief.
Stem Cells for Pain Inside Knee
Stem cells retain the ability to develop into any other types of cell in the body. The idea behind stem cell injections for pain inside knee is to inject the stem cells into damaged cartilage to stimulate growth of new cartilage for the joint.
Just like with PRP, there are variations in the formulations of stem cells used to inject onto the cartilage surface.
The few patients that I have had go through stem cell injections for joint pain have had good results and, with the exception of the current costs of stem cell injections, I’m a fan of this type of approach.
With both PRP and stem cells, you obviously need an intact joint. This means that, if you are considering a joint replacement, you might want to wait a few more years, just in case the field of regenerative medicine continues to move forward. Once you’ve had a joint replacement, it’s too late to take advantage.
Take Home Messages for Pain Inside Knee
Knee pain is a significant problem in today’s society. It leads to a drastically reduced quality of life and ability to participate and enjoy life, especially as we age.
All too often, society thinks that drugs and surgery are the only real options. Hopefully, since you’ve made it this far (and didn’t just skip to the ending credits), you understand that there are lots of other options to both prevent knee degeneration from starting in the first place and help provide arthritis knee pain relief once it starts.
Here’s to healthier knees and better quality of life.