18 Aug

Dr Win’s Clinical Reflections (13) What Are We Actually Treating? Lessons From a Complex Case of Chronic Knee Pain

by PhD.Win In: Win huang clinical reflection - 0 Comment

Dr Win’s Clinical Reflections (13)

What Are We Actually Treating? Lessons From a Complex Case of Chronic Knee Pain

By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)

Recently, I treated a patient who had experienced right lateral knee pain for approximately five years.

On imaging alone, this did not look like a straightforward case.

He had undergone multiple investigations, including MRI, X-ray and ultrasound, as well as specialist assessment. The findings included significant lateral compartment degeneration, full-thickness cartilage damage, meniscal tears, synovitis, joint effusion, a Baker’s cyst, thickening of the iliotibial band and other degenerative changes.

His history also included abnormalities involving the right hip and an L5/S1 disc bulge.

There was also a substantial treatment history. He had undergone two meniscal operations, the first around 2022 and the second approximately 18 months before I saw him. He had also received an injection and tried acupuncture, physiotherapy and spinal manipulation.

Before his second knee operation, he had experienced pain in almost exactly the same lateral knee region. At that time, the pain was frequently around 5–6/10, which contributed to the decision to proceed with surgery.

The surgery did help. For approximately one year afterwards, he was almost pain-free.

Then, during the following months, pain gradually returned in essentially the same area.

This raises an important clinical question:

When pain returns to the same location, does that necessarily mean the same damaged structure is causing it again?

A Pain Pattern That Did Not Completely Match the Imaging

The patient works as a chef and spends much of his working day standing and walking.

After a long day at work, his lateral knee pain could reach 5–6/10.

Yet there was something unusual about the pattern.

He is physically active, regularly cycles and trains at the gym. During cycling, he generally did not experience his typical knee pain. Gym training also did not significantly provoke it.

In contrast, prolonged standing at work—or even sitting in a car for a long period without changing position—was more likely to bring the pain on.

In other words:

Dynamic exercise did not necessarily aggravate the pain, while sustained loading and prolonged static positions often did.

That pattern made me reluctant to explain his current symptoms simply by pointing to a meniscal tear or cartilage loss on MRI.

Imaging tells us what structural abnormalities are present.

It does not always tell us which structure is generating the patient’s pain at that particular moment.

The Examination Added Another Piece to the Puzzle

At the initial assessment, right knee flexion was markedly restricted.

Using the same position for comparison, the heel-to-buttock distance was approximately 22 cm on the right, compared with approximately 5 cm on the left.

There was also marked tenderness around the posterolateral aspect of the knee.

The patient repeatedly described another long-standing symptom that he himself called “nerve pain”: tightness, aching and discomfort extending from the lateral knee into the upper lateral calf, occasionally accompanied by numbness in the foot.

His description did not by itself establish a specific nerve entrapment diagnosis.

But it was clinically relevant.

My attention therefore began to shift from one question—

“What is damaged on the scan?”

—to another:

“Apart from these established structural abnormalities, what else may be contributing to or amplifying his current pain?”

Why Did I Focus on the Lateral Popliteal Region?

One examination finding particularly caught my attention: pronounced tenderness in the lateral aspect of the popliteal region behind the knee.

This is an anatomically complex area containing muscles, tendons, fascia and periarticular tissues, with important neural structures also passing through the region.

Tenderness there does not automatically mean that a particular nerve is entrapped. Nor can one tender point establish the source of chronic knee pain.

However, the finding became more meaningful when considered alongside the rest of the clinical picture:

lateral knee pain;
tightness extending into the upper lateral calf;
occasional foot numbness;
marked restriction of knee flexion;
and a symptom pattern that was more easily provoked by prolonged standing or sustained positioning than by cycling or gym exercise.

For this reason, my initial treatment did not focus primarily on trying to “treat” the meniscal tear, cartilage defect or Baker’s cyst described in the imaging reports.

Instead, treatment was guided by the physical examination, with particular attention to the posterolateral knee, surrounding soft tissues and areas of possible neural mechanosensitivity.

I was not looking for an alternative explanation simply because imaging had failed to provide one.

Rather, the patient’s symptoms, physical findings and imaging did not completely align. Clinical reasoning therefore had to continue beyond the scan.

What Changed After Five Treatments?

After the first treatment, the patient reported that the leg felt easier.

With subsequent treatments, the pain that had previously reached 5–6/10 after prolonged work progressively reduced.

The marked posterolateral tenderness also decreased.

Knee flexion improved substantially. The right heel-to-buttock distance, initially around 22 cm, progressively improved until it was approximately 5–6 cm, close to the left side at approximately 5 cm.

By the fourth and fifth visits, the patient reported very little pain during normal daily life.

Importantly, I specifically asked whether he had reduced his workload or exercise.

He had not.

He continued working as a chef, standing and walking for prolonged periods. He also continued cycling and training at the gym.

Even after a full working day, his discomfort was generally around 1–2/10 and at most approximately 3/10. The previous episodes of 5–6/10 pain had largely disappeared.

This makes it less likely that the improvement could simply be explained by resting the knee.

But this is where the case becomes more interesting.

There is no evidence that five acupuncture treatments repaired his meniscal tears.

There is no evidence that his full-thickness cartilage loss regenerated.

And there is no reason to believe that established degenerative changes of the knee structurally reversed within such a short period.

So what actually changed?

An Abnormality Can Be Real Without Being the Main Pain Generator

The meniscal damage, cartilage loss, osteoarthritic changes, synovitis, effusion and Baker’s cyst seen on this patient’s investigations are real.

The point is not to dismiss imaging.

The point is that:

The presence of a structural abnormality does not necessarily mean that it is the sole—or even the dominant—source of the patient’s current pain.

Several abnormalities can coexist in the same knee, yet their contribution to symptoms may be very different.

One may be an important pain generator.

Another may form part of the underlying pathology without directly producing the patient’s present symptoms.

Another may alter biomechanics and function.

And some findings may have been present for a long time without explaining why the patient hurts more today than yesterday.

This is why clinical reasoning cannot end when the MRI report arrives.

We still need to ask:

Where exactly does it hurt?

What brings the pain on?

What surprisingly does not bring it on?

Which examination findings reproduce the patient’s familiar symptoms?

Those questions can sometimes tell us as much about the patient’s current problem as another look at the scan.

Treating What Can Still Change

This may be the most important lesson I took from this case.

If every abnormality on an MRI becomes the direct target of conservative treatment, a case like this can appear almost impossible.

The cartilage is damaged.

The meniscus has been injured.

The joint is degenerative.

There is synovial change, fluid and a Baker’s cyst.

If our definition of successful acupuncture treatment is that all of these structural abnormalities must return to normal on imaging, then much of this is beyond what acupuncture can realistically achieve.

But a patient is not an MRI scan.

Even when structural pathology remains, other components of the clinical picture may still be modifiable.

Pain sensitivity may change.

Protective muscular tension may change.

Periarticular soft-tissue function may change.

Neural mechanosensitivity may change.

Movement and load distribution may change.

Joint mobility may change.

In this patient, the structural abnormalities almost certainly did not fundamentally change over five treatments.

Yet his work-related pain reduced from 5–6/10 to approximately 1–3/10, while his markedly restricted knee flexion returned close to the opposite side.

That tells us something important:

A meaningful component of his pain and functional restriction was modifiable.

Exactly how much of that change came from soft tissue, neural mechanosensitivity, pain modulation, protective muscle tension or an interaction between several mechanisms remains uncertain.

Treatment response should not be used to “prove” a diagnosis that has not otherwise been established.

Finding What Is Possible Within What Cannot Be Changed

Imaging deserves respect.

Some structural conditions require further medical investigation. Some patients need medication, injections or surgery. Conservative treatment cannot and should not replace every form of medical care.

But a serious-looking scan should not automatically lead us to conclude that every symptom must come directly from those abnormalities.

For clinicians using acupuncture and other conservative approaches, the question is therefore not simply:

“How do I fix everything on this MRI?”

A more useful question may be:

“Within this patient’s condition, what remains modifiable?”

Which restrictions are fixed, and which are reversible?

Which symptoms change with posture or activity?

Which examination findings reproduce the patient’s familiar pain?

Which findings improve in parallel with the patient’s function?

Finding those modifiable components can turn an apparently “untreatable” structural problem into a clinical situation in which meaningful improvement may still be possible.

Three Questions I Took From This Case

After five treatments, this patient had experienced substantial improvement in pain and function.

His structural knee pathology, however, still exists, and whether the improvement will remain stable over the longer term requires continued observation.

I therefore do not present this case as evidence that acupuncture “healed” a meniscal tear or regenerated damaged knee cartilage.

For me, its value lies in three questions:

1. What abnormalities have the investigations identified?

2. What is actually generating or contributing to the patient’s pain now?

3. What did our treatment really change?

Keeping these questions separate is important.

Imaging helps us understand structure.

The patient’s history tells us how the condition behaves.

Physical examination, treatment response and repeated reassessment help us understand which components may actually be contributing to the patient’s current symptoms—and which of those components may still be changed.

We should never treat only the scan. We treat the person behind it: a person who is in pain, who needs to move and work, and whose body may still have considerable capacity to adapt, recover and function better.

Book an Appointment

Persistent knee pain can have more than one contributing factor. A detailed history and clinical examination can help determine whether acupuncture may be appropriate for your condition.

Book an appointment with PhD Win Acupuncture Clinic:
https://booking.mananotes.co.nz/PHD-WIN/v2

Disclaimer

This article is a clinical reflection based on an individual case and is provided for general educational purposes only. It does not establish that acupuncture repairs meniscal tears, regenerates damaged cartilage or reverses structural osteoarthritis. Individual causes of knee pain and responses to treatment vary. Persistent, severe or worsening knee symptoms should be appropriately assessed by a qualified healthcare professional.