Osteo-Arthritis Knee joint

The technique of “Unmasking and treating the underlying problem”:

This technique is being explained for the first time (1,14) . It is a source of new hope for these patients, and gives promising results. It also gives us the clue and the knowledge of a new etiology for the symptom of Pain Knee Joint. Clinically our work has proved that the pain knee is due to lesions that are outside the joint and the aging process has nothing to do with it. These lesions may appear as early as 35 years of age and are invariably found in all those cases of Osteo-arthritis knee joint that clinically present with Pain Knee. Why these lesions develop is a question yet to be answered, but anyway they are well demarcated, identifiable and severely tender on deep palpation. These lesions when treated give complete relief to the symptom of Pain Knee, thus certain other treatment modalities would be required to be postponed, till the time that the patient escapes any benefit from this new technique.

However a big task is still lying ahead. This new algorithm needs to be authenticated and standardized by designing bigger treatment models. Their results evaluated and follow-ups carried out. Till date this new algorithm only gives us a clue of the etiology of pain knee and a new possible treatment technique.

Physical Examination

Physical examination findings in patients with this disease are mostly limited to the affected joints.
A deep, achy joint pain, presumably arising from a combination of mechanisms, is the main presenting symptom of osteoarthritis. Also, reduced range of motion and crepitus are frequently present.
Malalignment with a bony enlargement (depending on the disease’s severity) may occur. Most cases of osteoarthritis do not involve erythema or warmth over the affected joints however, an effusion may be present.
Limitation of joint motion or muscle atrophy around a more severely affected joint may occur.

What's new in Physical Examination:

However far more important is the new deep palpation technique. Adopted in the very initial stages of the disease, this will guide the physician to the lesions. These lesions are more important than the rest of the findings. As only these if properly treated will give the patient more than 90% relief and years of pain free living. In advanced stages of the disease the rest of the degenerative processes may then be contributing to the clinical symptoms and in severe cases they may even take over being the cause of clinical symptoms of pain, but the importance of these lesions are never lessened in any stage of the disease. Whenever identified and treated they will give remarkable relief to the symptom of pain.

However the rest of the findings in the joint may be of academic and prognostic interest and contribute little to the clinical symptoms.

Syed Zahid Hussain Bokhari, Latest on Osteoarthritis and Myalgia: The Technique of "Unmasking and treating the underlying problem. ISBN: 978-3-8454-3712-5 “LAP LAMBERT Academic Publishing, 2011

Trigger Points as the cause of Pain Knee:

Pain in the knee as explained above is due to trigger spots that are outside the joint proper (1) . As this etiology has been explained for the first time thus it is more appropriate to term this problem as Pain knee joint rather than OA knee joint. Reduction in joint space, neither thinning of the surface cartilage nor drying of the synovial fluid is the primary cause of this problem. This latest work on this diseases process completely negates the conventional concepts about the etiology of the pain knee.

Davidson's Principal & practice of Medicine indicates that by the age of 65, 80% of people have radiographic evidence of OA. Though only 25-30 % are symptomatic (17) . Thus among 80% who have Radiological evidence of OA changes in the joint only a third exhibit symptoms. It raises the question why the rest 50-60 % of patients remain asymptomatic, despite the fact that they also have those pathological changes. From these evidences it can also be concluded that there may be another cause for this problem. The conventional concept that is still being held may not be the cause of pain knee joint.

These trigger spots outside the joint proper are in the ligaments or tendons (1).These are highly tender points and patient can hardly bear the palpation at these trigger spots. These mainly cause the pain and the pain is referred to the most sensitive organ in near vicinity, the joint proper. During palpation at times nodes are felt palpable higher on the length of these tendons. These probably are the degenerative changes of the tendons. These nodes are the sites of highest tenderness.

Tendonitis or underlying synovitis may be the complication of the OA changes. So we can conclude that the complications of the OA (Tendonitis on these trigger points) are in fact causing the pain and not the OA changes (inside the joint) themselves. Thus we shall direct our efforts towards treating the complications rather than the joint.

Syed Zahid Hussain Bokhari, Latest on Osteoarthritis and Myalgia: The Technique of "Unmasking and treating the underlying problem. ISBN: 978-3-8454-3712-5 " LAP LAMBERT Academic Publishing, 2011

Trigger spots identified around knee joint are as under:

1. Above the joint on the medial side it is on the Adductor Tubercle, possibly the insertion of Adductor Magnus (Fibro Osseous Junction).
2. Higher up on the tendons and ligaments in the same line on the medial side. May be these are tendonitis or with associated underlying Bursitis.
3. On Lateral side it is on the origin of the Gastronemius lateral head (Fibro Osseous Junction).
4. Higher up on the tendons and ligaments in the same line on the Lateral side. May be these are tendonitis or with associated underlying Bursitis.
5. Underneath the upper border of Patella (this is very rare).
6. On the medial aspect of the joint upon Tibial Collateral Ligament ( Pes anserine bursa).
7. On the Dorsum above the popliteal fossa.

The first and the third points are invariably found in all the cases presenting with Pain Knee joint. Rarely a patient may have only one of them. These points are basically causing the main symptom of pain as we clinically see in our everyday practice. Why these sites are more prone to develop these pathological changes is a very important question that needs to be answered.

However other questions that are looking forward towards us for explaining the etiology and pathogenesis of this disease are:

• What in particular is the pathology at these sites?
• Why are certain people more prone to develop these changes while others are not?
• Can these be prevented?
• Are these posture related?
• Having identified them what are the most effective options to treat them?

The fifth trigger point is only found rarely and is always of mild intensity. It exhibits itself after the points of higher intensity had been treated. This may be bursitis (Supra patellar Bursa) and responds well to the injection therapy.

The lesion on the tibial collateral ligament happens to be stubborn. Not often it responds favorably to injection therapy. Prolotherapy may be a good option for treating this point.

Lesion on the dorsum of the knee, above the popliteal fossa is a typical point that causes pain that radiate to Knee as well the calf muscles. Thus it is advisable that this point must be palpated in case of any unexplained pain in the calf muscles for a possible etiology and differential diagnosis.

Thus this concept opens for us new venues and direction for research. It is particularly to be noted that modern medical research is emphasizing on the biochemical changes as the possible cause of Osteoarthritis. However it seems that the biochemical changes in these patients may be the result of long standing painful condition rather than a cause of it.

Prolotherapy as another Option:

Injection therapy termed as Prolotherapy is again an experimental procedure that seems to be showing promising results in treating these trigger spots. This is being practiced by certain physician. In this treatment regimen certain combinations of chemicals are injected at the site of tendonitis. This therapy is based on the philosophy of creating controlled, localized, inflammatory process at the site of lesion. It is postulated that this localized controlled inflammatory process will stimulate the macrophages to gather at the site of injection (site of Lesion). These macrophages will ingest the dead cells and will give way to the tendon to regenerate. This is a slow process and requires serial sittings. Various level of success has been claimed in this experimental procedure. Patient satisfaction has also been demonstrated by those who were subjected to this therapeutic technique.

However for this therapeutic technique to be successful, thorough knowledge and exact location of these trigger spots are most important. The success of the treatment will lie in pinpointing the trigger spots (the site of lesion). To achieve the same "unmasking pain knee" is utmost important.

Basic Root Level Discovery:

This latest development gives a new hope. This is a basic, root level discovery. It would result into giving altogether new direction to the research on the subject. Modern research has gone engaged into molecular level research while this factor may altogether demand that the research shall be directed towards these organic factors that are evident and demonstrable.

Acupuncture in Pain knee:

Acupuncture has remained an ancillary technique in this therapeutic regimen. Electro Acupuncture is given only for two to three days to relieve the pain in and around the joint. During this procedure the spasm of the Muscles around the knee joint is also relieved. Muscles spasm prevents free access to the lesions during palpation. Once this spasm is relieved palpation makes it possible to pinpoint the lesion within an error of 2-4 mm.

This is the success of the treatment

Syed Zahid Hussain Bokhari, Latest on Osteoarthritis and Myalgia: The Technique of "Unmasking and treating the underlying problem. ISBN: 978-3-8454-3712-5 " LAP LAMBERT Academic Publishing, 2011