In this episode of PodMD, Specialist Pain Medicine Physician and Specialist Anaesthetist Dr Liam Ring will be dicussing the topic of knee pain after knee replacement surgery, including what this type of knee pain is, the management options, the likelihood of it becoming a chronic condition, when to refer and more.
- Transcript
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*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Liam Ring
Dr Liam Ring is an Australian trained Specialist Pain Medicine Physician. He has a special interest in multidisciplinary and interventional pain medicine.
Today, we’ll be discussing the topic of Knee pain after knee replacement surgery.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.Liam, thanks for talking with us on Pod MD today.
Liam: It’s a pleasure to be here with you
Question 1
The topic of today’s discussion is knee pain after knee replacement surgery. Can you describe for our listeners what this particular knee pain is?Liam: Look, any ongoing knee pain following surgery, I guess, a better way to describe it would be, um, knee pain that persists below, beyond the expected time of healing following that knee operation.
Question 2
How would a patient with post-surgery knee pain typically present?Liam: So patients will typically present with, ongoing pain, knee pain, either similar or different, to the pain that they had prior to their knee replacement surgery.
Question 3
What are the management options?Liam: In all of those patients, it’s important to, uh, assess them for, uh, early complications, uh, early surgical complications. So related to the prosthesis or infection, vascular compromise, neurological compromise. Um, and if there’s any particular concern with regards to those factors, having them, uh, immediately assessed by their surgeon. Um, most of these patients should have seen their surgeon in the immediate post-operative period, but, uh, if you’re, if a GPS concern in any way, uh, I’d have a very low threshold for having them being seen again, um, in a setting where immediate surgical complications are ruled out, um, the focus of management would be to try and assess, uh, the nature of the pain from my perspective, trying to discern whether there is any neuropathic pain contributing or whether it is just musculoskeletal nociceptive pain.
Where a surgeon is happy with the knee replacement and there’s no concerning biological features there. Um, it’s very important for a patient to be reassured with regards to the structural integrity, integrity of their knee, uh, and educated about pain, uh, persistent pain wherein the pain they’re experiencing is not associated with any actual or ongoing harm, uh, and the importance of them, encouraging and guiding the patient with regards to exercise and upgrading their exercise. Uh, some patients having had knee replacement surgery, uh, assessed by a hospital physiotherapist, given some education and then sent home. Um, if that’s the case, linking that patient up, uh, with, uh, appropriate physical therapist, whether that be an exercise physiologist or physiotherapist, uh, would be strongly recommended, uh, ideally that clinician will then reiterate the education that you’ve established, uh, and then specifically guide them with respect to exercises to slowly upgrade the movement, uh, and functional use of their knee.
Um, I would also, I would encourage clinicians when assessing a patient, uh, that has persistent post knee surgery pain to thoroughly assess them for any evidence of focal neuropathic pain. Uh, so assessing their, the patient’s symptoms, uh, with neuropathic descriptors, uh, pain that could be of a spontaneous nature or any symptoms related to allodynia, um, assess them for, uh, for any indicative signs. So altered sensation in the area of pain or allodynia in that same area of pain. Um, and in a setting where a patient has focal neuropathic pain, uh, I would emphasize the importance of, um, educating the patient about neuropathic pain surrounding them by, with, um, appropriately trained allied health professionals to guide them in both psychological and physical desensitization, as well as, uh, graded exercise and exposure, uh, but also have a low threshold to consider, uh, first-line agents for neuropathic pain. I would encourage the provider to assess them quite regularly. And in the short term, if the patient’s not responding to those interventions, uh, suggest early referral to a pain medicine specialist,
So for focal, uh, knee pain, following a knee arthroplasty, if conservative management, uh, has failed, um, pain medicine, physicians have a few interventional options that can be helpful. Um, pulsed radiofrequency, innovation of genicular nerves, uh, can help with, um, mechanical knee pain. Um, it’s a simple day procedure. It’s not neuro disruptive so can be repeated and in the right patient can significantly reduce pain for 6-12 months and can facilitate active rehabilitation. If a patient has focal neuropathic pain around their knee, uh, following knee replacement surgery, um, if medications and other conservative management strategies aren’t helpful, uh, electrical neuromodulation can be helpful, particularly, uh, newer developments with a dorsal root ganglion stimulation. Um, you can target the L three nerve root or either side of it, uh, and that can be quite helpful in just targeting stimulation to the knee, uh, and can significantly reduce, uh, knee pain in selected patients.
If those things are ruled out, the next key thing to assess would be the presence of any definite neuropathic pain. If you’ve ruled out all of those things, we’re just dealing with, uh, persistent post-surgical pain associated with central nervous system sensitivity, uh, and then the importance of management management should focus on education, reassurance and guidance by appropriately trained allied health professionals in slowly upgrading their activity despite pain.
Question 4
Are there any warning signs, aside from biological, a GP, surgeon or patient can look out for pre or post-surgery?Liam: Well, the key thing we should be talking about, uh, if there is no biological, uh, concerns, uh, assessing the psychosocial social context is always advisable. Um, medical professionals are very good at ruling in and ruling out biological conditions, but, um, we also need to spend the time to assess a patient’s psychosocial context, um, addressing those stressors or factors, uh, is vitally important, and it takes time to properly assess that patient. And it might actually take referral to, uh, allied health professionals like psychologists, uh, or counselors to better tease that out or even social workers, uh, to tease that out. Um, and if those factors aren’t addressed, uh, the patient’s symptoms could be quite refractory.
Question 5
What is the likelihood of knee pain post knee replacement surgery becoming a chronic condition?Liam: Across the globe. The studies would show that approximately 20% of patients who’ve had knee arthroplasty have pain that is the same or worse than, uh, what it was prior to the surgery or their functions the same or worse than it was prior to the surgery. So for an operation that’s primary aim is to improve pain and function. That’s a significant proportion of patients that don’t have that either have that outcome. Um, so the incidence is relatively high.
Question 6
When should a GP or surgeon refer?Liam: A GP should be referring a patient on, uh, as early as possible, if there’s any concern with respect to, uh, biological concerns with regards to the, uh, knee arthroplasty, um, or if they’ve identified focal neuropathic pain, uh, that’s refractory to, uh, initial management. Um, I would suggest that a surgeon should refer patient onto a pain medicine specialist. Should they encounter a patient where they’re very happy with their prosthesis? They’re happy with the structural integrity of the joint and the neuro muscular and vascular structures around it. Um, and yeah, referring them to a pain medicine specialist early is, uh, is indicated.
Question 7
What role does the GP or surgeon play in the treatment of the condition?Liam: A GPs role in the early stages would be, uh, to consider, uh, analgesic medication. Um, but again, but I would ensure or encourage them, uh, to be clear with the patient and clear in their own minds as to what the actual aims of those medications would be. Uh, primarily I would encourage them to, uh, be used to reduce pain with an aim, to upgrade activity with an aim to slowly reduce them, uh, within an agreed timeframe but that might need to be reevaluated over time.
Concluding Question
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on post-surgery knee pain?Liam: First of all, persistent post, uh, knee surgery pain is more common than most people would realize. So the incidence incidence is approximately 20%. Um, I would encourage all clinicians to assess both pain and function in all these patients in the, in the many months following, um, ideally a patient’s on a trajectory where their pain and function is improving, but, uh, should, uh, GPS or surgeons identify that neither of these are either or neither of these things are happening. Uh, they should have a low threshold to investigate, uh, and refer them on to either a payments and specialist or the relevant surgeon. That’s a further assessment depending on their concerns.
A second take home message, uh, would be to, if we’re reassured by the structural integrity of the joint, um, assessing for neuropathic pain, uh, is vitally important, uh, because there are good, uh, medications and therapies available for that or interventions available for that. Um, should that be identified.
If a clinician has established that there is no sort of concerns, with regards to structural integrity as a joint or a neuromuscular vascular function around the joint. Um, I would encourage them to explore whether or not there’s any, uh, psychosocial contributors, uh, to that person’s pain, uh, and encourage them to work at trying to identify what those factors are, if they exist and refer them to appropriate, uh, allied health professionals for their management.
Thanks for your time and the insights you’ve provided.
Liam: Thank you.
