Optimizing Knee Pain
Chronic axial neck and back pain have long been the domain of radiofrequency ablation, and in my clinical practice I have seen countless patients benefit from this evidence-based technique. Over the past decade, the application of RFA has expanded meaningfully — not only for axial spine pain, but for chronic joint pain, with a growing and particularly compelling body of evidence centered on the knee.
THE BASICS
Genicular Nerve Radiofrequency Ablation — and Why Knee Pain Management Has Changed
The landscape of knee osteoarthritis treatment has shifted considerably in recent years, and for good reason. Corticosteroid injections, once a routine first-line option, are increasingly discouraged in many clinical contexts due to concerns over cartilage degradation and cumulative systemic effects. Hyaluronic acid injections have lost favor in multiple guidelines, offering limited long-term benefit for a significant proportion of patients. That has prompted a necessary shift toward recovery-oriented, rehabilitation-focused care — and it has created an opening for interventional approaches that address the neural drivers of pain rather than the joint environment alone. At Osso Health, I emphasize a multimodal, nonoperative approach to knee pain. I also recognize that for patients with end-stage osteoarthritis, total knee arthroplasty remains the definitive treatment. The clinical question I am most interested in is how we get patients there — and through it — in the best possible condition.
WHERE IT BEGAN
A Practice Built From the Hardest Cases First
My experience with genicular nerve ablation started where many pain stories end: after surgery. The first patients I treated with this technique were those experiencing persistent knee pain following total knee replacement — patients who had exhausted conservative options, were not candidates for revision surgery, and were living with ongoing pain that had no clear remaining treatment pathway. Using targeted thermal radiofrequency ablation of the genicular nerves, I was able to achieve meaningful pain relief and restore function for these patients without additional surgery or long-term medication dependence. Encouraged by those outcomes, I extended the same approach to patients with end-stage osteoarthritis who were delaying surgery for medical, logistical, or personal reasons. The results were consistent — offering a bridge that allowed them to maintain mobility, reduce medication reliance, and defer surgery while preserving quality of life.
KEY DISTINCTION
Thermal RFA, Cryoneurolysis, and How They Complement Each Other
Genicular nerve radiofrequency ablation uses controlled thermal energy delivered through image-guided needles to interrupt the sensory nerve pathways responsible for transmitting knee pain. It is performed under fluoroscopic or ultrasound guidance targeting the superolateral, superomedial, and inferomedial genicular nerves — the primary afferent contributors to knee joint pain. The procedure is outpatient, requires no implants, and produces no significant tissue damage beyond the targeted nerve. In addition to thermal ablation, I now offer cryoneurolysis for the genicular nerves — a technique that applies subzero temperatures to desensitize peripheral nerves through a reversible axonotmesis rather than thermal destruction. Cryoneurolysis offers a favorable sensory profile and may be particularly well-suited to patients with post-arthroplasty discomfort or those seeking temporary relief prior to planned surgery, where the reversibility of the effect is clinically advantageous.
CLINICAL EVIDENCE
What Does the Research Show?
The evidence base for genicular nerve RFA has grown substantially over the past decade. Multiple randomized controlled trials and systematic reviews have demonstrated statistically significant improvements in pain scores and functional outcomes compared to sham procedures and conservative care in patients with knee osteoarthritis. The preoperative application of genicular nerve RFA represents an emerging and particularly promising frontier. Early evidence supports this strategy, demonstrating improved postoperative pain control, enhanced early rehabilitation and mobilization, shorter hospital stays, fewer postoperative complications, and no increased risk of infection when RFA is performed prior to total knee arthroplasty. The mechanistic rationale is straightforward: by interrupting the chronic afferent pain signal before surgery, patients arrive in better neurological and functional condition for recovery, with lower baseline central sensitization and reduced perioperative opioid requirements.
PATIENT SELECTION
Who Is a Good Candidate?
Genicular nerve RFA is appropriate for patients with chronic knee pain secondary to osteoarthritis who have had an inadequate response to conservative management including physical therapy, oral medications, and intra-articular injections. It is also appropriate for patients with persistent pain following total knee arthroplasty who are not candidates for or do not wish to pursue revision surgery. Preoperative RFA should be considered for patients planning total knee arthroplasty who have significant chronic pain burden, high baseline opioid use, or risk factors for difficult postoperative pain management. As with all interventional procedures, precise patient selection and diagnostic accuracy are the primary determinants of outcome. A careful clinical evaluation and imaging review are essential before any recommendation is made.
FOR REFERRING CLINICIANS
Genicular nerve radiofrequency ablation and cryoneurolysis represent important additions to the perioperative and nonoperative management of knee pain, and I welcome referrals from orthopedic surgeons, primary care physicians, and other specialists managing this population. Whether the goal is optimizing a patient before planned total knee arthroplasty, managing persistent pain after joint replacement, or providing a durable nonoperative option for patients who are not surgical candidates, I offer a comprehensive evaluation, image-guided procedural expertise, and clear documentation back to the referring provider. My background includes extensive collaboration with surgeons across spine, total joint, upper extremity, and foot and ankle specialties. I understand the nuances of perioperative musculoskeletal care and the importance of a referring relationship built on communication and shared goals. I welcome direct physician-to-physician consultation.
PERSPECTIVE
A Note on Collaborative Perioperative Care
The management of chronic knee pain has for too long been treated as a binary — conservative care on one side, surgery on the other — with little attention paid to the interventional space between them and even less to what happens in the weeks and months surrounding the surgical episode itself. Perioperative pain management is not the surgeon's problem alone, and it is not solved by a standard anesthesia protocol. It requires a physician who understands the neuroscience of chronic pain, the biology of surgical recovery, and the specific nerve anatomy driving a given patient's experience. That is the role I aim to fill. When a patient arrives at surgery with years of central sensitization and a high baseline pain burden, the recovery is harder, the rehabilitation is slower, and the outcomes are less predictable. When that same patient has had their peripheral pain signal meaningfully reduced before the procedure, the entire postoperative course changes. That is not a theoretical benefit — it is what the evidence shows, and it is what I see in clinical practice. The opportunity to contribute meaningfully to surgical outcomes without being in the operating room is one I take seriously.
DISCLOSURE & REFERENCES
This article is for educational purposes and reflects clinical experience and interpretation of published literature. It is not a substitute for individualized medical evaluation. Key references: Choi WJ et al. 2011 (genicular nerve RFA, Pain); Ikeuchi M et al. 2011 (genicular nerve block and ablation outcomes); McCormick ZL et al. 2017 (systematic review, genicular RFA, Pain Med); Fonkoué L et al. 2019 (genicular nerve anatomy); Dasa V et al. 2021 (preoperative cryoneurolysis and TKA outcomes, J Arthroplasty); Radnovich R et al. 2017 (cryoneurolysis RCT, Osteoarthritis Cartilage).
ABOUT THE AUTHOR
Dr. Mahajer is a double board-certified physiatrist and sports medicine physician, fellowship-trained in Interventional Spine & Sports Medicine at the Icahn School of Medicine at Mount Sinai. He is an Assistant Professor of Neuroscience at FIU Herbert Wertheim College of Medicine. He is the Immediate Past President of the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR), holds medical licenses in Florida, New York, and California, and has been recognized as a Top Physiatrist and Top Doctor in both Florida and New York.
