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Non-Surgical
Osteoarthritis
(OA) is a condition which progresses slowly over a period of many years.
Osteoarthritis cannot be cured. Treatment is directed at decreasing the
symptoms of the condition, and slowing the progress of the condition.
First, realize you are not alone. OA of the knee is a condition many people
face. But thanks to continued advances in medicine, there are now many
treatment options available. Recent information now shows that your condition
may be maintained, and in some cases it may even improve. So let's look
at some ways to get your knee feeling better, to get it in tiptop shape,
and to keep it that way!
Our first goal,
then, will be to help reduce pain in the knee. Your physician may prescribe
acetaminophen (Tylenol), a mild analgesic, as an excellent first-line
pain reliever in this problem. Some people may also get relief of pain
with anti-inflammatory medication, such as ibuprofen and aspirin. In either
case, medications should be used in combination with physical therapy.
If the symptoms
continue, a cortisone injection may be used to bring the inflammation
under better control and ease your pain. Cortisone is a very powerful
anti-inflammatory medication, but does have secondary effects that limit
its usefulness in the treatment of osteoarthritis. The major drawback
in the use of multiple injections of cortisone is the fact that it may
actually speed up the process of degeneration when used repeatedly. Repeated
injections also increase the risk of developing a knee joint infection,
called a septic arthritis. Any time a joint is entered with a needle,
there is the possibility of an infection. Most physicians use cortisone
sparingly, and avoid multiple injections unless the joint is already in
the end stages of degeneration where the next step is an artificial knee
replacement.
Recently, a
new type of injectable medication has become available in the US. Hyaluronic
acid preparations have been used in Europe and Canada for several years
and seem to be beneficial in decreasing the symptoms in knees that have
mild to moderate osteoarthritis changes. The medication requires 3 to
5 injections given over a one month period. The medication seems to reduce
symptoms in many patients for 6-8 months.
In the Beginning...
Limit pain:
Your physical therapist has several tools, or modalities, to help control
the acute symptoms caused by osteoarthritis of the knee. Sources of heat,
like a moist hot pack, ultrasound, or diathermy, can help reduce discomfort
by stimulating blood flow and overriding pain sensation. Joint mobilization
may be chosen for its ability to provide nutrition and lubrication to
the joint surfaces. It is also helpful for overriding the transmission
of pain to the brain. Another helpful treatment to reduce pain is transcutaneous
nerve stimulation (TENS for short), which uses a mild electrical impulse
to block pain. Certain topical ointments (such as Capsaicin) can also
help limit pain.
Increase range
of motion: By improving knee movement, you may find that pain symptoms
ease. Another benefit of gaining more motion is that it keeps the joint
surfaces healthy. And finally, it helps prepare your knee for higher levels
of activity. Range of motion can be gained with a pool exercise program,
gentle stretching by your therapist, or with the use of a stationary bike.
Increase strength:
In the early stages, strengthening may be done using isometric exercise.
These are exercises in which the muscles contract, but the joint stays
in one position. Isometrics help restore strength while protecting you
from further pain and irritation. As your muscles gain strength, you may
notice less pain in the knee while feeling a sense of ease with walking
and doing general activities.
Practice
Joint Protection...
Muscular control:
Sometimes the knee gets an extra jolt when you accidentally miss a stair
or when you stub your toe. Untrained leg muscles are slow to respond in
protecting the knee joint, and these jolting forces do more damage to
the softer bone under the cartilage. A trained muscle will generate force
quickly. Conditioning exercises help knee muscles generate forces more
quickly, acting as shock absorbers in protecting the knee joint.
Walking aids:
A cane or walker may be suggested by your physical therapist. Using a
walking aid can take some of the stress off the joint, protecting it from
undue stress and strain.
Shock absorption:
A good pair of shoes will help reduce shock. Also, if you choose walking
as your primary exercise, choose a walking surface like cinder or grass.
Avoid cemented or other hard surfaces. If you find that increasing your
walking speed irritates your knee, limit your speed. Other exercises that
prevent high impact shock include stationary biking and swimming.
Alignment:
When the knee is not properly aligned, extra pressure may develop on one
side of the knee joint. In these cases, a special shoe insert, or orthotic,
with a heel wedge can help relieve pressure and pain. Sometimes an osteoarthritis
knee brace may be chosen. These braces are designed to unload the pressure,
whether on the inside or outside of the knee joint.
Daily activities:
Here are some helpful hints to use during the day to limit strain on your
knee.
Avoid standing
for greater than 10 minutes; instead use a high stool or take frequent
rests.
Limit stair climbing; take the elevator, escalator, or ramp.
Avoid bending and squatting; keep items at waist level, or use a reached.
Park close to your destination.
Avoid low beds, chairs, and toilets; elevate them when possible.
As Your
Treatment Progresses...
Daily exercise:
Your joint surfaces can remain healthier by consistently working your
leg through a full range of motion and using safe, load-bearing exercises.
Use exercise to keep the hip, knee, and ankle muscles strong. Avoid pain
by working in a pain-free arc of movement, limiting walking speeds, and
overstressing the knee. In the presence of pain, use static, isometric
exercise.
General fitness:
The Surgeon General recommends that everyone get 30 minutes of moderate
activity a day for as many as seven days a week. Along with reducing the
risk of heart disease, lowering stress, managing body weight, and prolonging
life, a general fitness program can also assist you in managing OA of
the knee. Before undertaking such a program, consult your physician. Moderate
activity can include walking, swimming, stationary biking, or low impact
aerobics.
Exercise progression:
Your exercise program will be advanced cautiously to include strengthening,
balance, endurance, and functional activities. Your program will address
key muscle groups of the buttock and hips, thigh, and calf. Several exercise
choices can further stabilize and control the knee. Finally, a select
group of exercises can be used to simulate day-to-day activities like
raising up on your toes or standing from a raised stool. Specific exercises
may then be chosen to simulate work or hobby demands.
Long Term
Management...
Here are some
long-term solutions to help manage OA of the knee:
Control pain
and inflammation.
Reduce shock by using a walking aid, wearing good shoes, choosing soft
surfaces, and keeping the leg muscles conditioned for unexpected stresses.
Exercise daily to maintain range of motion, strength, and cardiovascular
fitness.
Use a shoe orthotic with a heel wedge for better alignment.
Take precautions with daily activities to avoid stressing the knee.
There are also braces on the market now that can reduce the pressure on
the side of the knee that is most involved. These braces have been designed
mainly for the more common condition of early wear and tear in the medial
compartment of the knee. A brace may help with your pain and is worth
experimenting with.
Surgical
Treatment
Arthroscopy
Arthroscopy
is sometimes useful in the treatment of osteoarthritis of the knee. Looking
directly at the articular cartilage surfaces of the knee is the most accurate
way of determining how advanced the osteoarthritis is. Arthroscopy also
allows the surgeon to debride the knee joint. Debridement essentially
consists of cleaning out the joint of all debris and loose fragments.
During the debridment any loose fragments of cartilage are removed and
the knee is washed with a saline (salt) solution. (WASH.AVI) The areas
of the knee joint which are badly worn may be roughened with a burr to
promote the growth of new cartilage - a fibrocartilage material that is
similar scar tissue. (BURR.AVI) Debridement of the knee using the arthroscope
is not 100% successful. If successful, it usually affords temporary relief
of symptoms for somewhere between 6 months - 2 years.
Proximal
Tibial Osteotomy
Osteoarthritis
usually affects the inside half (medial compartment) of the knee more
often than the outside (lateral compartment). This can lead to the lower
extremity becoming slightly bowlegged, or in medical terms, a genu varum
deformity. The result is that the weight bearing line of the lower extremity
moves more medially (towards the medial compartment of the knee). (It's
really all in the physics of the situation!) The end result is that there
is more pressure on the medial joint surfaces, which leads to more pain
and faster degeneration.
In some cases,
re-aligning the angles in the lower extremity can result in shifting the
weight-bearing line to the lateral compartment of the knee. This, presumably,
places the majority of the weight-bearing force into a healthier compartment.
The result is to reduce the pain and delay the progression of the degeneration
of the medial compartment.
The procedure
to re-align the angles of the lower extremity is called a Proximal Tibial
Osteotomy. In this procedure a wedge of bone is removed from the lateral
side of the upper tibia. This converts the extremity from being bow-legged
to knock-kneed. This procedure is not always successful, and generally
will reduce your pain, but not eliminate it altogether. The advantage
to this approach is that very active people still have their own knee
joint, and once the bone heals there are no restrictions to activity level.
The proximal
tibial osteotomy in the best of circumstances is probably only temporary.
It is thought that this operation buys some time before ultimately needing
to perform a total knee replacement. The operation probably lasts for
5-7 years if successful.
Total Knee
Replacement
The ultimate
solution for osteoarthritis of the knee is to replace the joint surfaces
with an artificial knee joint. The decision to proceed with a total knee
replacement is usually only considered in people over the age of 60, (although
younger patients sometimes require the surgery simply because no other
acceptable solution is available to treat their condition). The main reason
that orthopedic surgeons are reluctant to perform the surgery on younger
individuals, is that the younger the patient, the more likely the artificial
joint will fail during the patient's lifetime. Replacing the knee again,
a process called a revision, is much harder, has more potential complications
and is less likely to be successful.
Artificial
knee joints last about 12 years in an elderly population. Younger patients
are more active and place more stress on the artificial joint. This can
lead to loosening and failure of the artificial knee earlier after surgery.
Obviously, younger patients are also more likely to outlive their artificial
joint, and will almost surely require a revision at some point down the
road. It is for these reasons that orthopedic surgeons are usually reluctant
to recommend a total knee replacement in the younger patient until there
are simply no other options.
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