Knee Pain

In the simplest terms, a joint occurs wherever two bones come together; however, that definition does not begin to convey the complexity of joints, which provide your body with flexibility, support and a wide range of motion.

You have four types of joints: fixed, pivot, ball-and-socket and hinge. Your knees are hinge joints. As the name suggests, they work much like the hinge of a door, allowing the joint to move backward and forward. Your knees are the largest and heaviest hinge joints in your body, and the most complex. In addition to bending and straightening, they twist and rotate. This makes them especially vulnerable to damage, which is why they sustain more injuries on average than do other joints.

A Closer Look at Your Knees

Your knee joint is essentially four bones held together by ligaments. Your thighbone (femur) makes up the top part of the joint, and two lower leg bones, the tibia and the fibula, comprise the lower part. The fourth bone, the patella, slides in a groove on the end of the femur.

Other structures in your knee include:

  • Ligaments: These are large bands of tissue that connect bones to one another. In the knee joint, four main ligaments link the femur to the tibia and help stabilize your knee as it moves through its arc of motion.
  • Tendons: These fibrous bands of tissue connect muscles to bones. Your knee has two important tendons, which make it possible for you to straighten or extend your leg: the quadriceps tendon, which connects the long quadriceps muscle on the front of your thigh to the patella, and the patellar tendon, which connects the patella to the tibia.
  • Meniscus: This C-shaped cartilage curves around the inside and outside of your knee, cushioning your knee joint.
  • Bursae: A number of these fluid-filled sacs surround your kneeand help cushion your knee joint, so that ligaments and tendons slide across it smoothly.

Normally, all of these structures work together efficiently, but injury and disease can disrupt this balance, resulting in pain, muscle weakness and decreased function.

Some common causes of knee pain and injuries include:

  • A ruptured ligament or torn cartilage, resulting from forceful contact during sports, a fall or a car accident
  • Repeated stress or overuse, which may occur from playing sports or if your work or hobby requires repetition of the same activity
  • Sudden turning, pivoting, stopping, or cutting from side to side, which happens frequently during certain sports
  • Awkward landings from a fall or jumping during sports, such as basketball
  • Rapidly growing bones, which are especially prone to injury during sports
  • Degeneration from aging or medical conditions, including arthritis, gout and infection

If you’re suffering from knee pain, you are not alone. Almost one in three Americans older than age 45 reportssome type of knee pain. It is a common cause for doctor and emergency room visits.

Some of the more common knee injuries and their signs and symptoms include the following:

Ligament Injuries: Your knee contains four ligaments — tough bands of tissue that connect your thighbone (femur) to your lower leg bones (tibia and fibula). You have two collateral ligaments — one on the inside (medial collateral ligament) and one on the outside (lateral collateral ligament) of each knee. The other two ligaments are inside your knee and cross each other as they stretch diagonally from the bottom of your thighbone to the top of your shinbone (tibia). The posterior cruciate ligament (PCL) connects to the back of your shinbone, and the anterior cruciate ligament (ACL) connects near the front of your shinbone. A tear in one of these ligaments, which may be caused by a fall or contact trauma, is likely to cause:

  • Immediate pain that worsens when you try to walk or bend your knee
  • A popping sound
  • An inability to bear weight on the injured knee
  • A feeling that the knee might buckle or give way

Tendon Injuries (tendinitis): Tendinitis is irritation and inflammation of one or more tendons — the thick, fibrous cords that attach muscles to bones. Athletes, especially runners, skiers and cyclists, are prone to develop inflammation in the patellar tendon, which connects the quadriceps muscle on the front of the thigh to the larger lower leg bone (tibia). If your knee pain is caused by tendinitis, some of the signs and symptoms include:

  • Pain, in one or both knees
  • Swelling in the front of the knee or just below the kneecap
  • Worsening pain when you jump, run, squat or climb stairs
  • An inability to completely extend or straighten your knee

Meniscus injuries: The meniscus is a C-shaped piece of cartilage that curves within your knee joint. Meniscus injuries involve tears in the cartilage, which can occur in various places and configurations. Signs and symptoms of this type of injury include:

  • Pain
  • Mild to moderate swelling that occurs slowly, around 24 to 36 hours after the injury
  • An inability to straighten the knee completely; the knee may feel locked in place

Bursitis: Some knee injuries cause inflammation in the bursae, the small sacs of fluid that cushion the outside of your knee joint so that tendons and ligaments glide smoothly over the joint. Bursitis can lead to:

  • Warmth
  • Swelling
  • Redness
  • Pain, even at rest
  • Aching or stiffness when you walk
  • Considerable pain when you kneel or go up and down stairs
  • Fever, pain and swelling if the bursa located over your kneecap bone (prepatellar bursa) becomes infected

Loose body: Sometimes a piece of bone or cartilage will break off and float in the joint space because it has degenerated or sustained injury. This may not create any problems unless the loose body interferes with knee joint movement. The effect is similar to a pencil caught in a door hinge — leading to pain and a locked joint.

Iliotibial band syndrome: This occurs when the ligament that extends from the outside of your pelvic bone to the outside of your tibia (iliotibial band) becomes so tight that it rubs against the outer portion of your femur. Distance runners are especially susceptible to iliotibial band syndrome, which generally causes:

  • A sharp, burning pain on the outer side of the knee that usually begins after longer distance runs
  • Pain that initially goes away with rest from running, but in time, may persist when you walk or go up and down stairs

With this type of knee injury, there usually isn’t swelling and you’ll likely have normal range of motion.

Rheumatoid arthritis: The most debilitating of the more than 100 types of arthritis, rheumatoid arthritis can affect almost any joint in your body, including your knees. Common signs and symptoms include:

  • Pain
  • Swelling
  • Aching and stiffness, especially when you get up in the morning or after periods of inactivity
  • Loss of motion in your knees and eventually deformity of the knee joints
  • Sometimes, a low-grade fever and a general sense of not feeling well (malaise)

Although rheumatoid arthritis is a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares, often alternate with periods of remission.
Osteoarthritis: Sometimes called degenerative arthritis, this is the most common type of arthritis. It’s a wear-and-tear condition that occurs when the cartilage in your knee deteriorates with use and age. Osteoarthritis usually develops gradually and tends to cause:

  • Varying degrees of pain, especially when you stand or walk
  • Swelling
  • Stiffness, especially in the morning and after you’ve been active
  • Creaking or popping sounds
  • A loss of flexibility in your knee joints

Chondromalacia of the patella, or patellofemoral pain: These are general terms that refer to pain arising between your patella and the underlying thighbone (femur). It is common in young adults ( especially those who have a slight misalignment of the kneecap), in athletes and in older adults who usually develop the condition as a result of arthritis of the kneecap. Chondromalacia of the patella causes:

  • Pain and tenderness in the front of your knee that worsens when you sit for long periods, get up from a chair, and climb or descend stairs
  • A grating or grinding sensation may be present when you extend your knee

How Is Knee Pain Diagnosed?

History and Examination: A history of your complaints including duration, what makes it better and worse is very important. Previous treatments and outcomes, as well as orthopedic examination of the muscles, joint, movement and strength are also used for diagnosis

X-rays: Plain X-rays can show narrowing of the space in the two joints of the knee —revealing wear and tear on the cartilage from arthritis like diseases and bone spurs that can interfere with movement.

MRI: Magnetic Resonance Imaging: Is a noninvasive procedure that can reveal the detail of knee ligaments, tendons and cartilage including tears in the meniscus.

Myelography/CT scanning: Sometimes used as an alternative to MRI

Diagnostic ultrasound Imaging: Unlike an x-ray, which emits radiation and shows only bone, diagnostic ultrasound is non-invasive and allows for viewing the causes of your knee joint pain with great accuracy. With musculoskeletal ultrasound imaging (MSUS), the muscles, tendons, ligaments, cartilage and joint can be accurately examined at the time of your visit. This provides immediate information about the health of your joint and what factors are contributing to your pain. With this information in hand, specific treatment options can be established immediately!


When the joint is painful or damaged there are a variety of successful treatment options.

Why are ultrasound-guided injections better and more accurate?

When using an injection to deliver treatment into painful joints, it is necessary to be exact and precise.

Dr. Isidro and his team are highly trained in ultrasound-guided injections. These procedures are performed in the office, at the time of your visit. Some of the common structures involved in joint pain may be as little as 2-3mm wide and therefore require a high level of precision to be accurate. In addition, when performing an injection, there are also structures that you want to avoid so you don’t knick or damage them on your way into the joint. The ultrasound machine provides live imaging in real time, to safely place injectable medications or treatments into or around the joint with laser-like precision.

Consider trying to hit a target blindfolded¾you may know the general direction but would not be certain if you have actually hit your target. With live ultrasound imaging, the targeted areas of pain are viewed in real time while the injection is taking place, guiding the needle with pin-point accuracy!

Cortisone Injection: Painful arthritic joints, chronic tendinitis, bursitis and inflammation respond quickly to cortisone. In many cases this is the head start patients need to allow for gains with more conservative care and no further treatment is required. Many patients think that cortisone is bad for you. Too much of anything is not good. Using cortisone infrequently, as much as several times per year will not do any harm. If the pain continues to return, other treatment options should be considered.Cortisone is injected using continuous live ultrasound guidance exactly where it is needed to quickly reduce inflammation and pain.

New Treatment Using LIPOGEMS® Could Be the Answer for Arthritis Pain

LIPOGEMS® is a new treatment option for arthritis pain now offered by Dr. Norma Bilbool, M.D., a double board certified physician specializing in Physical Medicine and Rehabilitation and Pain Medicine and Richard D. Striano D.C., RMSK Registered in Diagnostic Medical Musculoskeletal Sonography. The combination of advanced imaging techniques with ultrasound to diagnose and precisely guide treatment, and physician experience with treating all joints with minimally invasiveLIPOGEMS® has led to the majority of patients treated having significant improvement with less pan, improved function and quality of life.

LIPOGEMS® could be the solution to those who suffer from pain in the shoulder, lower back, hip, knee, ankle and other joints including the rotator. Optimum Joint, is equipped and has been performing ongoing clinical studies on the shoulder, rotator cuff, lower back, hip and ankle pain where a patient’s own fat is used to alleviate arthritis related conditions many of which have failed to respond to other treatment methods including bone-on-bone joints. Optimum was among the first practices in the USA trained in the state-of-the-art treatment through LIPOGEMS® technology that is a minimally invasive same day procedure, performed in about an hour, using local anesthetic with no sedation required and no down time. This could be the answer for many of those looking to avoid surgery.

The Autologous (fat from you and put back into you) Micro-Fragmented Adipose Tissue (LIPOGEMS®) is a NEW technology where fat is taken from the patient, using a local anesthetic, washed, and micro-fragmented, using the LIPOGEMS® system. Micro-fragmented fat using the LIPOGEMS® system mechanically supports and cushions joints, and holds regenerative capabilities and when re-injected can decrease inflammation, cushion, repair or replace defects in damaged tendons and cartilage, or other tissue.

The fat is injected using continuous ultrasound guidance to ensure pin point accuracy in treating the joint and surrounding damaged tendons to repair and restructure damaged tissue with pin-point accuracy. Research has shown non-guided “blind” injections are accurate 36% – 60% of the time while ultrasound guided injections are 100% accurate. Accuracy in delivering regenerative treatments is essential. We are evaluating the LIPOGEMS®, made with an FDA cleared device, for their ability to cushion, repair, or replace damaged tissue and the regenerative effects of the fat it contains, to jump-start repair and decrease inflammation.

“This is an extraordinary study because of its use of micro-fragmented fat tissue, which makes it more bioavailable to the area we inject, and by using the precision of ultrasound guidance the treatment is visualized being delivered to each area of the joint and tissues in need of repair. This combination of support and regenerative regenerative elements with the precision of advanced ultrasound guidance is contributing to the long term impressive results.

 NEW STUDY: Adipose tissue contains Adipose Derived Stem Cells “ADSC’s” and more than 600 secreted proteins and included key molecules involved in tissue regeneration. Stem Cell Res Ther. 2015; 6: 221.

NEW STUDY: Lipogems Product Treatment Increases the Proliferation Rate of Human Tendon Stem Cells without Affecting Their Stemness and Differentiation Capability. Results showed that the Lipogems product significantly increases the proliferation rate of hTSCs (human tendon stem cells). Moreover, treated cells increase the expression of VEGF, which is crucial for tissue healing. Stem Cells International Volume 2016 (2016), Article ID 4373410, 11 pages

Dr’s Bilbool and Striano are among few doctors in the country offering IRB- approved regenerative treatment options, with a focus on minimally invasive alternatives to surgery. Their work has been recognized and new studies are being published this year.

Lubrication for Arthritis:

Why Hyalgan?

A squeaky gear needs the most oil!

The joints of the body are normally surrounded by a lubricant and shock absorber called Synovial fluid. Patients with osteoarthritis experience pain and inflammation because arthritic damage in thejoint causes the Synovial fluid to break down over time.

This process causes increased friction and excess wear and tear on the cartilage cushioning movement that becomes rough and jagged causing the joint further deteriorate. Range of motion, walking, getting up from a seated position, climbing and descending steps and weight bearing is often painful. Pain is often increased during or after activity.

What is Hyalgan?

Hyalgan is a naturally derived lubricant that instantly cushions and lubricates painful arthritic joints. By restoring lubrication and cushion, your joints move more freely again with less friction and most importantly, less pain. Hyalgan is injected using continuous live ultrasound guidance ensuring pin-point accuracy exactly where it is needed.

Platelet Rich Plasma Therapy (PRP): Jump starting the healing signals:

Why use PRP?

When there is damage, tissue tears or arthritis, this exciting new procedure (made popular by professional athletes) that heals damaged structures in a joint such as the labrum, tendons, muscle, ligament or cartilage is showing exciting results!

How does PRP work?

When you cut your skin and it bleeds, platelets collect and gather at the wound site. Once there, platelets act like a conductor in an orchestra. They release growth factors that signal the healing activities to begin, resulting in a cascade of events that restore the damaged tissue.

Joints, however, do not have a direct blood supply. Therefore, when a joint structure is damaged or torn, platelets do not gather and orchestrate the necessary events for that damage to be restored. Joint damage either heals slowly or not at all. That is where Platelet Rich Plasma Therapy (PRP) proves valuable!

How is the procedure performed?

By taking a small sample of your blood, a special centrifuge concentrates and separates the platelets, growth factors and specialized white blood cells from the other components of the blood. This super concentrated PRP is then injected using continuous ultrasound guidance into the cracks and crevices of the damaged area. The orchestra of events is stimulated and the tissue begins to heal. The result is reduced inflammation and pain.

Lipogems Regenerative Medicine: Healing Damage – Tears and Chronic Tendinitis:

As with the explanation above regarding platelets, damage in the body is healed by an orchestrated cascade of events guided by the release of specific growth factors in the areas where damage occurs. Because joints and surrounding tendons lack a direct blood supply, damage heals slowly or often not at all.

Lipogems Regenerative Medicine is hydrolyzed micronized amniotic membrane allograft. Lipogems Regenerative Medicine contains 13 powerful growth factors. That’s a mouth full! Amniotic Membrane has been used in wound healing for many years. By placing the allograft over wounds that aren’t healing, as with burn victims, new tissue grows. Just recently, the allograft has been processed into a form that is dehydrated and micronized.

Lipogems Regenerative Medicine is pre-packaged and injected using continuous, live ultrasound guidance exactly where the damage is. This begins to jump start and boost the healing response so joints function better with less inflammation and less pain.

Have you tried Physical Therapy in the past and it hasn’t worked for you?

A Different Approach Other Than Routine Painful Exercises:

We see many patients who come to us in chronic pain. Many have also had experience with physical therapy where they spent much of their sessions doing exercises and it hasn’t helped. Think of being in pain, having joint stiffness, loss of range of motion or chronic inflammation and then doing exercises to get rid of it. In most cases, you’ll feel worse not better.

Exercise is critical to maintain proper joint strength, but done at the wrong time and your pain often becomes worse. That is why we take an entirely different approach with treatment plans using three phases:

  • Therapeutic Modalities:

Our physical therapy team specializes in using certain modalities like electrical stimulation or ultrasound to reduce swelling and inflammation and increase local circulation to help the healing process. Different modalities can be applied to successfully address spasm, trigger points, inflammation, edema, swelling and damage from tendonitis and tears.

  • Joint Release Techniques:

Techniques are done by hand to gently stretch, massage and release the pressure in each of the muscles, tendons and ligaments surrounding the joint. The result is a soothing improvement in joint pain.

  • The Selective Functional Movement Assessment:

Our physical therapy team is certified in the Selective Functional Movement Assessment (SFMA), which is a series of 7 full body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known joint pain. When the clinical assessment is initiated from the perspective of the movement pattern, our therapy team has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main joint pain complaint, but contribute to the pain.

Think of having a painful right knee and favoring that side for an extended period of time. Following a period of uneven gait you may develop pain on the opposite unrelated side. This concept, known as Regional Interdependence, is the hallmark of the SFMA.

The assessment guides our clinical physical therapist to the most dysfunctional non-painful movement pattern, which is then assessed in detail. By addressing the most dysfunctional non-painful pattern, the application of targeted interventions (manual therapy and therapeutic exercise) is not adversely affected by pain.

When to see a doctor 

You should see your doctor if:

  • You’re experiencing severe knee pain
  • You’re activities are becoming restricted
  • You have increased pain with activity
  • You have pain that is gradually increasing over time
  • You’ve been told you have arthritis
  • You have pain lasting more than two weeks



Can an OptimumJoint traditional or regenerative medical procedure help me? To find out if you might be a candidate for an OptimumJoint medical treatment procedure, complete our Optimum Joint Procedure Candidate Form online.