chronic knee pain

November 13, 2008 4:40 PM

My husband has been seeking treatment for chronic knee pain (both knees) for a couple years now.

His GP, who rarely spends more than 4 minutes talking to him, has:
-- prescribed Tylenol 3 and ice, which do alleviate the pain
-- taken x-rays, which showed nothing wrong
-- decided that the muscles around the knees must be weak and sent him to physiotherapy, and the exercises they gave him have had no effect after several months
-- told him to go to an orthopedic surgeon

My husband feels like the doctor has no idea what is wrong and is just grabbing at straws. He says the pain, while bad, is not serious enough to require surgery and therefore does not want to see the surgeon. He also doesn't want to have x-rays again because he's already had them once. He feels the whole thing is a waste of time, but neither of us can come up with a better idea, besides doing nothing, which means living with the pain. He's very busy with work and doesn't have time to spend half a day in an orthopedic surgeon's office, only to be told they can't find anything wrong or want to do surgery that he doesn't want.

The knee pain started after he became mostly sentient, following a couple years of good fitness where he was weight training regularly. He ran track in high school. He is now 40 and weighs about 180 lbs., approx. 6' tall. He has orthopedic inserts in his shoes after a large corn (or something; a big lump on the ball of his foot) was causing him to walk funny, which combined with muscle weakness likely started the knee pain.

Is there anything else he can do? Changing GPs would be risky, because he might not be able to continue getting the Tylenol 3. Doctors around here are extremely paranoid about prescribing narcotics, and some refuse to do it at all. His current GP gives him the hairy eyeball every time he asks for a refill. Is the orthopedic surgeon really an orthopedic specialist, able to explore the problem more fully and offer alternatives, or are they strictly focused on surgery (i.e. the advice would be either "surgery" or "not surgery")? Why would he need a second set of x-rays? Would rigorous strength training in the legs help?

Thanks in advance for any advice.

throwaway email: [e-mail]

posted by anonymous to health & fitness (14 answers total)

knee pain started after he became mostly sentient

This word, sentient? I do not think it means what you think it means.

Your husband seems to be taking Tylenol 3 consistently. This stuff is hard on your liver, and (I think, IANAD) is probably not really meant to be used long-term. If he's just taking it to mask the pain, it's doing nothing to solve the underlying problem. If there wasn't an underlying problem, he wouldn't have chronic knee pain.

He might need a second set of x-rays because, you know, they might have missed something in the first set. Maybe it was a bad angle, bad exposure, bad technique, who knows?

My guess is that rigorous strength training for the legs would probably be a bad idea. It might just aggravate the problems that your husband is already having. Is your husband doing the exercises recommended by the physiotherapist consistently? He needs to be disciplined about it and do them exactly the way the physio showed him.

It does sound like your GP is out of their element here. I suggest going to the orthopedic surgeon. They may or may not recommend surgery, but it's pretty much guaranteed that they will have a better idea what the problem is, and be better informed about the possible remedies, surgical or not.
posted by number9dream at 5:43 PM on November 13, 2008

Tylenol 3 is not for chronic pain! If used that way it will likely make him an addict. Use it for a few days, weeks at most then stop.

He needs to see an orthopedist and get a proper evaluation. There are HA products which can be injected to ease symptoms for a few months. Physical therapy and proper training are probably in order. It all depends upon the exact problem, but it is likely cartilage breaking down and there are not good surgical solutions for those yet, although things are improving.
posted by caddis at 6:07 PM on November 13, 2008

follow-up from the OP

"Yes, sorry, I meant sedentary, not sentient! Freudian slip maybe?

No need to comment as to the Tylenol 3; we are aware of the dangers, and his doctor is aware of how long he's been on it. Thanks, and keep the suggestions coming!"

posted by jessamyn at 6:25 PM on November 13, 2008

My chronic knee pain / tenderness was cured when I saw a very good pedorthist who built a great pair of orthotics for me.
posted by TorontoSandy at 6:38 PM on November 13, 2008

It sounds like his posture/gait has changed as a result of his foot problem, and maybe his orthotics are not doing what they are supposed to be doing to correct that. His knee pain would result from compensating for his feet being off-kilter. If his PT isn't doing anything to help after several months, then he needs to change PTs. My experience/observation with PT (I work with PTs & have benefited from them as well) has been: big improvement right off the bat, then slow & steady progress, with regular changes to the therapy and home-exercises to keep things improving.

(If he only saw the PT once or twice and it's the home-exercises that have not shown improvement, then he needs to be really really honest about how much he is doing them. Again, my observation with PT is that patients rarely follow through with the recommended exercises.)
posted by headnsouth at 6:52 PM on November 13, 2008

He should consider seeing a pain management specialist, or a 'pain doctor'. This kind of doctor is more knowledgeable about treating chronic pain than GPs (and will likely be able to prescribe more appropriate meds than T3). They are also trained in providing non-surgical options for managing pain, which sounds like more the direction you're hoping to go, rather than jumping straight to surgery. Call your insurance company, and they will help you find a pain specialist in your area. Good luck!
posted by oceanmorning at 8:29 PM on November 13, 2008

Acupuncture for pain. Really.
posted by pointilist at 10:28 PM on November 13, 2008

Squat.

StartingStrength.com
posted by tiburon at 11:08 PM on November 13, 2008

Is the orthopedic surgeon really an orthopedic specialist, able to explore the problem more fully and offer alternatives, or are they strictly focused on surgery (i.e. the advice would be either "surgery" or "not surgery")?

In this case, the surgeon is also a specialist. Your husband should go see an orthopedic surgeon/consultant/specialist, who is far more qualified to diagnose your husband's condition than a GP. It is difficult to give you advice on how your husband can manage/deal with the pain without a conclusive diagnosis from an orthopedic specialist. I'm not sure what it's like in your country, but where I'm from (1st world, developed nation), an appointment with an orthopedic specialist at a private clinic normally lasts about an hour or two, including the time you spend in the waiting room waiting for your turn. Obviously you should call ahead to make an appointment. Seeing a specialist might take longer if he/she suggests that your husband get an MRI of his knees; but in some cases this is an important step in the process of diagnosing what sort of problem your husband has with his knees.

I have bad knees as well, and had to go to a specialist to get my condition properly diagnosed. X-rays showed nothing wrong either.
posted by nihraguk at 1:19 AM on November 14, 2008

"My husband .... says the pain, while bad, is not serious enough to require surgery and therefore does not want to see the surgeon."

This should an informed decision made after seeing a specialist. An orthopedic surgeon does more than operate. If they feel that is the best treatment option they will explain why, explain the alternatives, and then your husband decide.
posted by sero_venientibus_ossa at 4:52 AM on November 14, 2008

Is the orthopedic surgeon really an orthopedic specialist, able to explore the problem more fully and offer alternatives, or are they strictly focused on surgery (i.e. the advice would be either "surgery" or "not surgery")? Why would he need a second set of x-rays?

I broke my patella (kneecap) in a motor vehicle accident two weeks ago and am currently under the care of an orthopedic surgeon.

If the Ortho that your husband has been referred to is anything like mine, its the most full-service practice I've ever seen. His office includes facilities for x-rays and MRIs, physical therapy, brace and cast fitting, and can apparently treat pretty much every step of the rehab process in-house.

LOTS of people I've met there have had only very minor, arthroscopic surgery -- almost always on their knees. Its very possible that your husband has a small tear in some soft tissue (cartilage, tendon, ligament, etc.) that is causing the pain. Ultimately, however, its going to be an orthopedic practice, rather than a GP, who is in the best position to diagnose and appropriately treat what's wrong with him.

And, not to put to fine a point on it -- if your husband's pain is bad enough to require him to take Tylenol 3 every single day then its bad enough to require surgery. Yes, I'm sure he's busy. We're all busy. But better to spend a couple of days finding out what's really wrong and treating in than being in constant pain for the rest of your life.

Tell him to go to the Ortho.
posted by anastasiav at 5:33 AM on November 14, 2008

I've been seeing an orthopedic for my mild-moderate knee pain for about a year now. I've avoided anything surgical (including cortisone shots), and he has been totally OK with that.

My knee pain is very likely caused by my foot problems and how I've changed my gait to accommodate that.

What has worked best for me so far for knee pain that is on the interior lower area below/behind knee cap:
Glucosamine - this will not be an immediate fix, but it will help in the long term
"walking normally" - This is tough for me, but I'm trying. I have to balance out the foot and knee pain here
Not sitting on my leg (half "indian-style" in a chair) - This is a big one, at least in my case. Sitting in front of a computer all day with a leg under me did bad things to my knees. Stopping myself from doing this as much as possible has made a huge difference in pain levels.


I agree with all above who have recommended seeing an Ortho. They see these things all the time and know how to treat the issue properly.
posted by odi.et.amo at 7:02 AM on November 14, 2008

Erm... that'd be "orthopedist".
posted by odi.et.amo at 7:07 AM on November 14, 2008

I spent most of last spring and summer going through the same range of things your husband did: pain relief techniques, not-helpful x-rays, two months of PT 3x/week to strengthen and stabilize the muscles around the knee, with no improvement in knee pain despite marked improvement in strength and balance. Then the orthopedic surgeon.

Three weeks ago, I had arthroscopic surgery on my left knee. The surgeon repaired a tear in my meniscus and also found, and cleared out, some advanced arthritis--he showed me pictures from the surgery, my bone looked like a monster claw with long spikes of bone. I am still recovering, and can't yet walk up stairs or walk for exercise, although I can do all normal daily activities. But I can also tell that something that used to be wrong in there isn't wrong anymore. When I saw the surgeon for a follow-up visit, he said, "When you're done recovering, you're going to be very very happy for a long time," and I'm beginning to think he's right.

I was ambivalent about the surgery, in part because they wouldn't know what was wrong--if anything--or whether it was surgically fixable until they went in, so I understand your husband's concern that they don't really know. The surgeon I saw did seem focused on the surgery/no surgery question, but a friend who is a doctor and who advised me said that my knee symptoms were "classically surgical," particularly a feeling like the knee might give out on me, and partial locking with painful release.

I agree with earlier posters that if your husband needs Tylenol 3 to manage his pain, then a consultation with a specialist is certainly in order.
posted by not that girl at 3:06 PM on November 14, 2008