Knee Pain and Your Options

knee pain

What can I do about knee pain?

A patient once told me to appreciate my knees because they will go out long before you’re ready!  Knee pain is very difficult to deal with as literally every other step you take can be excruciating.  Let’s talk about some options for knee pain.
First, conservative things first!  You can treat many knee pains with the anacronym RICE: Rest, Ice, Compression, and Elevation.   Don’t forget OTC meds such as Tylenol, ibuprofen, and naproxen are options depending on your medical conditions.
After conservative treatments, consider physical therapy, aqua therapy, Airrosti, and knee braces.  Many times a little therapy and support can help resolve knee pain.  Furthermore, topical creams can be used with benefit.  You can also consider CBD cream which can provide significant anti-inflammatory benefits.  

If these options don’t help, that’s where we can help!  We routinely offer multiple options for patients with knee pain including:-  steroid injections:  used for inflammation/swelling-  viscosupplementation:  used as a lubricant for the knee joint for degeneration or arthritis pain-  Radiofrequency: a higher-level procedure where the nerves that go to the knee are burned, blocking only the pain signals that come from your knee.  This procedure is a very good option for people that have tried everything else with little benefit. Amazingly, we can even provide significant benefit in patients that have had a total knee replacement but still have pain!

What are the guidelines for maximal narcotic dosing?

The current guidelines state patients should avoid taking more than 90 MME of narcotics/day. MME means “morphine mg equivalents”.  This is a way to compare any narcotic to morphine so we can compare the strength of the other narcotic. 

For example, we all know what $100 is, but how much are 100 euros?  Or how much are 100 pesos?  Much like different country currency, the MME calculators will standardize narcotic dosing so we can figure out how much of any narcotic is in morphine doses. 

For example, oxycodone has an “exchange rate” of 1.5 mg to morphine.  So, 10 mg of oxycodone is actually equal to 15 mg of morphine.  (10 x 1.5= 15).  After converting your narcotics to morphine, you add up all the doses.  This total amount should not be more than 90 mg of morphine/day. 

If you are taking more than 90 MME /day, you are potentially putting yourself at risk for future challenges. You should discuss your long term goals about narcotics with your prescribing doctor. 

Maximum Daily Dose of Tylenol

how much Tylenol to take
Did you know the maximum daily dose of Tylenol is 4000 mg/day?  The maximum dose of ibuprofen (Advil) is 3200 mg.  But these are in patients with no other medical concerns such as kidney disease, liver disease, or GI concerns.  Ask us!  We are happy to help.
All short-acting narcotics should only be taken “PRN” which means as needed.  You should only take your narcotics as needed by your pain, never on a set schedule such as every morning, every lunch, every dinner and every night before bed.  If you’re doing better from therapy, non-narcotics, interventions, or other causes, you may not need your narcotics….so don’t take them.  There is much research showing long term narcotics make your situation worse.  You should strive to always try to get off of narcotics or decrease your requirements.

Injections Over A Year: How Many Is Enough?

There are varying guidelines from pain organizations about how many is the appropriate number of injections.  Usually, it comes down to less than 4 steroid injections per/year.  Realize, many injections don’t require steroids so they would not count in these numbers.

In the end, your insurance company will determine how many steroid injections and/or procedures you can get in a twelve-month period.  Feel free to look into your insurance pain procedure policies or just ask!

Why is my Neurontin (gabapentin) Not Working?

Many times we have patients that have tried neurontin and reported it does not work.  However, they dont realize the normal minimal dose needed to get a benefit is 1200 mg/day. 

On occasion patients try it and only go to 300 or 600 mg /day and then think it doesn’t work.  Make sure you give your meds a chance to work and follow the prescriptions before stopping. 

Please inform your doctors why the medicine was not working and what dose you were taking.  Many times, we just need to increase the dose more before a benefit comes.

When It’s Time to Consider Surgery

Generally, surgery is used for severe pain that has not improved with other modalities.  Just like pain procedures, there are many different types of surgery available.  Your surgical options will depend on your symptoms, exam, review of imaging studies, and your surgeon.  Dr. Moran knows many excellent surgeons across the city and will only refer to highly respected surgeons. 

Getting a Surgical Opinion 

 Just because you see a surgeon or Dr. Moran refers you to a surgeon, does NOT mean you will have surgery.  This is simply a chance for the surgeon to review your situation and then let you know if you are a good candidate for surgery.  You and you alone will decide if you want surgery.  Nothing will happen without your consent.  If you are a good candidate for surgery but do not want surgery, we can try other options to manage your pain.  

 It’s possible the surgeon did not think you are a good surgical candidate now and wants you to try to avoid surgery.  Or maybe the surgeon knows your insurance company will not approve surgery yet so wants us to try other things first before returning back to the surgeon and see if you meet the criteria then. 

Why Would I See A Surgeon For SCS Placement?

Because I want what’s best for you!  If you qualify for an SCS implant, we will refer you to a surgeon for evaluation and plans.  The surgeons we use for SCS placement are highly trained surgeons at the top of their fields.  Although Dr. Moran can do your surgery for placement, he knows the surgeons he uses are much better at surgery than he is. The surgery required for the SCS implant is relatively simple for a surgeon and usually takes less than one hour.  

Why Decadron Is Our Drug of Choice

Many people ask me injections.  And just like there are hundreds of ways to make a pizza, there are hundreds of ways to do injections! 

Variables include:

 -The approach or direction of the injection

-The technique or how the physician performs the procedure

-The mixture of medicines in the injection

-The local anesthetic used

-The volume of injection meds

-The imaging technique or the way the x-ray machine is used

 -The type of injection (we have already learned there are over 85 different injections just in the low back)

– And the choice of steroid 

In considering our choice of steroids, we prioritize patient safety over everything else.  Therefore, the steroid we routinely use is decadron, also called dexamethasone. 

There are many different types of steroids, each with its own characteristics.  Some last longer than others, some are safer than others, some are faster acting, some are cheaper, and they have different sizes.  Decadron is very small and non-particulate.  Therefore, it can be used IV, or injected directly into a vein, and not cause any problems, making decadron one of the very safest steroids to use during injections. Furthermore, it is one of the longest acting steroids, maximizing the benefit for the patient.  
When you are considering steroid injections, make sure you discuss with your physician their choice for which steroid they use and why.  Empower yourself with knowledge.  

What Does The Term “10/325” On My Narcotic Prescription Mean?

This is the way your meds are made. The first number is the dose of narcotic.  The second number is the dose of the other medicine, usually Tylenol.

For example, if you are taking Percocet 10/325, every single pill has 10 mg of oxycodone and 325 mg of Tylenol.

If you are taking Norco 5/325, every single pill has 5 mg of hydrocodone and 325 mg of Tylenol.  If you are taking Vicoprofen 10/200, every single pill has 10 mg of hydrocodone and 200 mg of ibuprofen.

Always ask your doctor if you have specific questions on your medications.