Knee replacement can be extremely painful. Previously, opioids or narcotics were administered for pain relief. But excessive addition of opioids is not exactly effective for controlling pain. 

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.

Multimodal denotes administering two or more than two types of medications that work with different mechanisms. The following are the techniques used:

Pre-operative Femoral Nerve Block: Prior to the surgery, a catheter is placed beside the femoral nerve for blocking it. This nerve is located in the upper thigh. Medication is delivered through the catheter for the nerve to be numbed for 24 hours. Thus, pain signals to the brain are blocked. This method reduces the use of narcotics and the consequent side effects.

Patient Controlled Analgesia (PCA): This method is also known as  Pain Pump . An intravenous pump is used to administer pain relief medications, such as oxymorphone or morphine, after the surgery. The control button of the machine could be pressed, by the patient for 6 to 10 times per hour. The machine is used for two post-operative days.

Oral Medications: The oral medications include Non-Steroidal Anti-Inflammatory drugs or NSAID; such as Celebrex which is similar to aspirin, structurally. Alternatively, acetaminophen, such as Tylenol or its equivalent composition, can also be used.

Acetaminophen: It acts on the Central Prostaglandin Synthesis and relieves the patient of pain through multiple mechanisms.

Epidural Analgesia: It produces lower pain scores and involves less time for achieving physical therapy goals. However, this is subject to side effects such as dizziness, urinary retention and itchiness.

Gabapentinoids: These medications include membrane stabilizers such as Gabapentin and Pregabalin.

The objective of multimodal treatments is to provide quick relief to the patient and immediately so. Earlier the rehabilitation, more successful will be the knee replacement surgery.

Multimodal Pain Relief After Total Knee Replacement

Causes and symptoms of knee pain

Knee pain is characterized by a feeling of pain in the knee joint caused by injury or overuse. The knee joint consists of small bone structures, the kneecap, supporting ligaments and cartilage of the knee. This joint bears the full weight of the body, which makes it very vulnerable to injury.

Causes of knee pain

Knee pain is usually caused by injuries to the knee such as exposure to a direct force on the knee, abnormal twisting of the knee or falling on your knees. Some causes of knee pain are -

Knee strains and sprains - Overworking the knee joints can damage the tissues of the knee joint resulting in knee sprains and strains

Osteoarthritis - it is condition where the protective cartilage around the kneecap is damaged, resulting in knee pain

Bursitis - Excessive movement of the knee or kneeling down for extended periods can irritate the bursa (a fluid sac below the skin above the knee joint) that causes swelling and pain, thereby giving rise to this condition

Gout - This condition is characterized by the accumulation of uric acid in crystal form around the knee joint, causing inflammation and pain

Tendon disorders - Tendons connect the muscles to the bones, and overworking the knee can cause the tendons around the knee to become sore and painful

Kneecap dislocation - Injuries may cause the kneecap to shift out of its position, this causes swelling and pain in the knee joint

Symptoms of knee pain

Severe knee pain can restrict movements such as walking or standing. The symptoms vary according to the extent of the damage suffered by the knee. Most common symptoms of knee pain are problems in climbing stairs, inability to extend the knees, limping and swelling of the knee joint. In some cases, knee pain may also cause fever.

Causes and Symptoms of Knee Pain

A meniscus tear is a common injury associated with the knee. The meniscus acts a defensive shield, providing a much-needed cushion to the knees, keeping it stable and injury free. Each knee joints contain two menisci located between the tibia and the femur. In this article, we will discuss important details related to meniscus tear to help you understand the injury better.

Facts related to a Meniscus Tear

A meniscus tear can affect all and sundry. However, sports persons (especially those associated with soccer, tennis, football, and basketball) and aged people are more susceptible to the condition.
As per Boston Children's Hospital, of late there has been a steady rise among children suffering from the meniscus tear.
Osteoarthritis may act as a catalyst, accelerating the chances of a meniscus tear.
In most of the times, a meniscus tear occurs when you exert immense pressure on the knee joints such as lifting a heavy object or suddenly standing up from a squatting position. With age, the meniscus is known to suffer from a natural wear and tear resulting in the injury.
As already mentioned, there are two menisci present in each knee joints. The one present inside the knee joint is called Medial Meniscus. Lateral Meniscus is the one present on the outer part of the joint.
Depending on the extent and severity of the injury, a meniscus tear may be
A minor tear: This is a small injury accompanied by mild pain and swelling which may last for not more than 2-3 weeks.
A moderate tear: The injury results in pain that are concentrated mainly around the center or the sides of the knee. The swelling goes from bad to worse over the next 2-3 days, with the person facing discomfort while bending their knee. The knee also stiffens. You may be relieved of the symptoms within a week or two but overusing the knee or twisting it may cause a relapse.
A severe tear: True to its name, your knee is the worst affected in this case. The cartilage tear may be such that the torn pieces get lodged in between the joint spaces causing the knee to lock, pop or even catch. A person experiences unbearable pain and discomfort along with stiffness and swelling (can be immediately following the injury or within 2-3 days). In the case of a severe meniscus tear, a person may not be able to straighten the knee at all (without treatment and medical intervention)
Treatment for a meniscus tear may be surgical or nonsurgical.
The nonsurgical treatment involves the application of cold compress on the affected area. The person needs to take ample rest exerting minimum pressure on the affected knee. Physiotherapy and strengthening exercise can go a long way in improving the condition. To reduce the pain and swelling, the doctor may prescribe painkillers and NSAIDs (Nonsteroidal Anti-Inflammatory Drugs). Keep the knee elevated. The use of elastic wraps may be helpful.

In extreme cases, surgery may help to treat the injury and the associated symptoms.

Facts About a Meniscus Tear!

Knee pain is one of the most common and painful ailments that can limit mobility. Injuries can result in cartilage or meniscal tears or sprains too. Obesity is another reason because of which knee pain is on the rise. Also, regular wear and tear of ligaments and tendons around the knees due to old age is another cause. These days, with reduced physical activities and sedentary lifestyles, the rate at which knees are wearing out has also become accelerated. Whatever the reason, a correct diagnosis followed by prompt treatment can help. Over the years, physiotherapy has been playing an important role in treating knee injuries. Whether to supplement the various drugs to reduce pain and inflammation or to avoid surgery, physiotherapy has helped many and its popularity is growing every day. Here are some ways that physiotherapy can help reduce pain.

Improve flexibility of tendons: The knee cap is an area where there are lot of tendons and ligaments, coordinating to enable movement. Careful exercising can ensure that the flexibility of tendons and ligaments is improved, thereby making your knee movement easier and less painful.
Improves blood supply: As we all know, proper movement requires good blood supply. Exercising with special focus on the knee ensures that blood supply is improved, and thereby the supporting ligaments and tendons function optimally.
Enhances the knee cap function: The knee cap is that portion which joins your thigh bone to your calf bones. This is prone to slip out of place, especially with arthritis and injuries. This can be painful and limit movement to a great degree. Focused exercises aimed at improving knee cap function will ensure that the knee cap has a wider range of function, and does not slip out of its socket easily.
Reduce rigidity: Once you start physiotherapy, you will feel your knees getting more flexible. The rigidity that had set in as a result of injuries and/or old age will also reduce over a period of time.
Slow down the wear and tear: When you start physiotherapy after knee damage, continuing the exercise routine, of course with expert guidance, can reduce the pace at which further damage might happen. A word of caution though. Be sure to consult an experienced physiotherapist before you begin. Exercising in a bad manner can do equal or more harm than the original injury or old age itself.

Knee Pain and Physiotherapy

Knee pain is something that can affect anyone - irrespective of their age. While sometimes it may be of minor importance - and can easily be handled by self-care, often, lingering pain is a manifestation of some other serious underlying problem, such as arthritis. In this case, it is imperative that you consult a doctor and take appropriate measures to combat it.

Causes :

Arthritis: The chief cause of lingering knee pain, arthritis itself can be of a number of types:
 Osteoarthritis, which is a result of deterioration of cartilages due to wear and tear
 Rheumatoid Arthritis, an inflammatory chronic disorder
 Septic Arthritis, causing pain, swelling and redness.
 Gout caused due to the development of uric acid crystals in the joints
Fractures: These are caused by the breaking up of the kneecap due to falls or collisions.
ACL Injuries: Caused due to the tearing of the anterior cruciate ligament (that connects the femur and the shinbone). Especially common in sportspersons such as footballers or basketball players.
Meniscus tears: The meniscus or the rubber-like cartilage (that acts as a shock absorber) can be torn by sudden jerks or excess pressure.

Symptoms:The major symptoms of knee pain include weakness, redness, instability, stiffness or the inability to properly straighten or move the leg. Often, a deformity is also visible, such as a bone sticking out of the leg - in which case it is advisable to consult a doctor immediately.

Possible risks :Factors which include the odds of being inflicted by knee pain and cause serious complications include :
Being overweight: This exponentially increases the stress or pressure that is applied on the knee joints - even in doing mundane tasks like walking up and down stairs.
Excessive physical activity: Some activities, such as sports apply excess stress on the knees as compared to other tasks.
Loss of muscle flexibility: Tightness or weakness in muscles causes increasing number of problems in the knees.

All About Knee Pain

Knee pain is a common phenomenon that plagues most of the people irrespective of their age. It can be the outcome of a torn cartilage or a ruptured ligament. Medical complications, such as infections, gout or arthritis (painful inflammation and stiffness of the joints) can also give way to knee pain. Minor knee pain can be eased by self-care remedies such as physical therapy or by putting on knee braces. However, few complications might demand surgical repair. Pain can be managed by the pain management specialists.

Tips to manage knee pain

1. Medications such as naproxen, ibuprofen and acetaminophen can be administered to help remedy knee pain.
2. You can seek relief by massaging your knees with ointments constituting of a number of agents such as capsaicin or lidocaine.
3. Keep away from your usual chores to prevent repetitive strains on the knees, thus, allowing the injury to heal as well as to stay safe from further damage.
4. Applying an ice pack in a towel can ease the inflammation and pain. But do not extend its usage for more than 20 minutes because that might harm the skin and nerves.
5. Compression bandages can inhibit fluid accumulation in the damaged tissues aiding knee alignment stability. Ensure that it is tight enough to render support to your knees without actually obstructing blood circulation.
6. To pacify the swelling, try resting your sore leg on a pillow (the idea here is to keep the affected leg elevated to reduce further pain).
7. Shed off your extra pounds as being overweight increases chances of other disorders such as osteoarthritis.
8. Go for regular work outs to enhance and maintain the flexibility of your muscles as excessively weak or abnormally tight muscles can contribute to injuries. Be smart while choosing your method of exercise based on the condition you are suffering from.

Knee Pain - 8 Effective Ways to Manage it

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