Approximately 9 million Americans currently battle with arthritis of the knee, in one form or another, on a daily basis. While there is no “cure,” effective treatment aims to reduce pain, stiffness, swelling and restore function. There are three basic types of arthritis that may affect the knee joint.
Osteoarthritis, commonly known as wear and tear arthritis, is a condition in which the natural cushioning between joints – cartilage – wears away. When this happens, the bones of the joints rub more closely against one another with less of the shock-absorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move and, sometimes, the formation of bone spurs.
Osteoarthritis is the most common type of arthritis. While it can occur even in young people, the chance of developing osteoarthritis goes up after age 45. According to the Arthritis Foundation, more than 27 million people in the U.S. have osteoarthritis, with the knee being one of the most commonly affected areas. Women are more likely to have osteoarthritis than men.
Knee arthritis symptoms tend to progress as the condition worsens. What is interesting about knee arthritis is that symptoms do not always progress steadily with time. Often patients report good months and bad months or symptoms that fluctuate with the weather. This is important to understand because comparing the symptoms of arthritis on one particular day may not accurately represent the overall progression of the condition.
The most common symptoms of knee arthritis are pain with activities; limited range of motion; stiffness of the knee; swelling of the joint; tenderness along the joint; a feeling the joint may “give out;” and deformity of the joint (knock-knees or bow-legs).
Evaluation of a patient with knee arthritis should begin with a physical examination and X-rays. When possible, these X-rays should be done standing and weight bearing. In the majority of patients with OA, an MRI is not necessary. X-rays can serve as a baseline to evaluate later examinations and determine progression of the condition.
If you have osteoarthritis of the knee, you can take advantage of a wide range of treatment options. The effectiveness of different treatments varies from person-to-person. The purpose of treatment is to reduce pain, increase function and generally reduce your symptoms. Patient satisfaction is a fundamental goal in treating osteoarthritis of the knee. Treatment of knee arthritis should begin with the most basic steps and progress to the more involved, possibly including surgery. Not all treatments are appropriate for every patient, and you should have a discussion with your doctor to determine which treatments are appropriate for your case.
In its early stages, arthritis of the knee is treated with nonsurgical measures. Nonsurgical treatments fall into four major groups: lifestyle modifications; exercise; supportive devices; and medications.
Lifestyle modifications can include losing weight, switching from running or jumping exercises to swimming or cycling and minimizing activities that aggravate the condition, such as climbing stairs. Many, but not all, people with osteoarthritis of the knee are overweight. Simple weight loss can reduce stress on weight bearing joints, such as the knee. Losing weight can result in reduced pain and increased function, particularly in walking. It has also been shown that activity modification, and especially weight loss, is really the only method that actually slows down the progression of arthritis
Exercises can help increase range of motion and flexibility as well as help strengthen the muscles in the leg. Physical therapy and exercise are often effective in reducing pain and improving function. Your physician or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.
Using supportive devices, such as a cane, wearing energy-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. Some research studies have focused on the use of knee braces for treatment of osteoarthritis of the knee. They may be especially helpful if the arthritis is centered on one side of the knee. A brace can assist with stability and function. There are two types of braces that are often used. An “unloader” brace shifts load away from the affected portion of the knee. A “support” brace helps support the entire knee load. In most studies, the knee symptoms improved, with a decrease in pain on weight bearing and a general ability to walk longer distances.
Several types of drugs can be used in treating arthritis of the knee. Because every patient is different, and because not all people respond the same to medications, your orthopedic surgeon will develop a program for your specific condition.
Over the counter medications can include aspirin, acetaminophen, naproxen or ibuprofen to help reduce swelling in the joint. Simple pain relievers, such as Tylenol, are available without a prescription and can be very effective in reducing pain. Pain relievers are usually the first choice of therapy for osteoarthritis of the knee. All drugs have potential side effects and simple analgesics are no exception. In addition, with time, your body can build up a tolerance, reducing the effects of the pain reliever. It is important to realize that these medications, although purchased over-the-counter, can also interact with other medications you are taking, such as blood-thinners. Be sure to discuss these issues with your orthopedist or primary physician.
A potent type of pain reliever is a nonsteroidal anti-inflammatory drug or nonsteroidal anti-inflammatory drugs, known as NSAIDs. These drugs, which include brands such as Motrin, Advil and Aleve, are available in both over-the-counter and prescription forms. Like all pain relievers, NSAIDs can cause side effects including changes in kidney and liver function as well as a reduction in the ability of blood to clot. These effects are usually reversible when the medication is discontinued.
Glucosamine and/or Chondroitin
Glucosamine and/or chondroitin sulfate may be particularly helpful in the early stages of osteoarthritis of the knee, provided they are used as directed on package inserts and with caution. Although glucosamine and chondroitin sulfate are natural substances, sometimes classified as food additives, they can cause side effects such as headaches, stomach upset, nausea, vomiting, and skin reactions. These supplements can interact with other medications, so keep your doctor informed about your use of them.
These substances can help reduce swelling and tenderness, as well as improve mobility and function. If you decide to take this therapy, it is important not to discontinue too soon. At least two months of continuous use is necessary before the full effect is realized.
Corticosteroids are powerful anti-inflammatory agents that can be injected into the joint. They are given for moderate to severe pain. They can be very useful if there is significant swelling, and are often used for acute flare ups, but are not very helpful if the arthritis affects the joint mechanics. However, the effects may not be long-lasting, Cortisone shots can be thought of as car washes, they don’t “wear off,” but cars do get dirty again, depending on how you drive and what you do to keep them clean.
Viscosupplementation with Hyaluronic Acid
Viscosupplementation involves injecting substances into the joint to improve the quality of the joint fluid. Early on these injections were obtained from rooster combs, and many people still refer to them as “chicken injections.” These are lubricants for the joint. When they are successful, these injections can reduce pain and eliminate the need for other medications. They are often done twice per year and can be repeated as long as they continue to provide relief.
More and more is being done with injections obtained from the patient’s own body. The most common of these injections, known as biologics, are stem cells and platelets. Neither of these are usually covered by insurance and can be quite costly. When they are successful, they do provide relief of symptoms, much as HA injections do, but they do not cure arthritis, as many advertisements claim.
If your arthritis does not respond to these nonsurgical treatments, you may need to have surgery. There are a number of surgical options, including the following: arthroscopic surgery to smooth torn or damaged cartilage, or to remove loose bodies; an osteotomy to improve the alignment of the knee joint; a total or partial knee arthroplasty replaces the severely damaged knee joint cartilage with metal and plastic; and cartilage grafting is possible for some knees with limited or contained cartilage loss from trauma or arthritis.
Here are 10 important things to keep in mind:
- Knee osteoarthritis is “wear and tear” of the knee. Knee arthritis occurs when the cartilage of the knee joint gradually erodes. Cartilage is a rubbery, slippery tissue at the ends of bones. Without the gliding, cushioning effect of cartilage, the bones of the knee joint rub together. The knee can’t move easily and becomes stiff, swollen, and painful.
- Symptoms usually develop gradually. Early symptoms of knee arthritis may be aching joints after physical activity or stiffness first thing in the morning. With time, symptoms may occur more often. It becomes harder to walk, climb stairs, and get in and out of chairs.
- Knee arthritis can affect your whole life. Although most people have mild knee arthritis, it can become severe. Knee arthritis can interfere with daily tasks and your ability to take part in family and work activities. Living with this painful condition can contribute to chronic mood disorders, such as depression and anxiety.
- There is no cure, but treatment can help. To relieve pain and stay active, you may need a multipronged approach. Weight loss, exercise, medication, alternative therapies, and surgery are some of the options.
- Trim your weight to ease knee stress. If you’re overweight, losing just 5 percent of your current weight can improve your arthritis symptoms. Every pound lost takes 4 pounds of stress off your knees. Shedding pounds isn’t easy, but a healthy weight will go a long way toward keeping you active.
- Exercise is one of the best treatments. Low-impact aerobic exercise, such as walking, swimming, water aerobics and cycling, relieves arthritis pain. Stretching and strengthening your leg muscles helps, too. Adding just a little activity to your day several times a week can make a difference in your symptoms.
- Medication combats pain and inflammation. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and topical creams and sprays are common therapies. Mild narcotic painkillers and injections of drugs that tame inflammation or improve joint lubrication are sometimes used. Which medication is best for you depends on the severity of your pain, your other health problems and the other medicines you take.
- Non-drug and alternative therapies may be worth trying. Physical therapy can improve joint function, while occupational therapy teaches you how to move smarter to minimize pain. Acupuncture, massage and electrical stimulation of the nerves (transcutaneous electrical nerve stimulation, or TENS) improve symptoms for some people.
- Self-care means less ouch. Pay attention to your body’s signals so you know when it’s time to slow down or rest. A good night’s sleep and a healthy diet will help you cope better with your arthritis. When flare-ups occur, apply hot or cold packs or warm towels to your knee or take a warm bath. Cold lessens inflammation, while heat boosts circulation and eases pain and stiffness.
- There are several surgical options. In knee replacement surgery, the entire knee or part of the knee is replaced with metal or plastic parts. This major surgical procedure can decrease pain and swelling and improve movement when the knee is very damaged. Removal of loose pieces of cartilage, smoothing of the knee’s bony surfaces, and realignment of the bones are other surgical procedures that can reduce pain and disability.
By Dr. Michael Gross
Dr. Michael Gross, the founder and director of Active Orthopedic and Sports Medicine, is the section chief of sports medicine and the orthopedic director of the Center for Sports Medicine at Hackensack University Medical Center, as well as medical director of Active Center for Health and Wellness.