Non Operative Treatment Options for Knee Arthritis
Knee arthritis is a common condition, which is increasing in prevalence and affecting more people at younger ages. This is occurring at a time when our population is living and staying active for longer. This poses a problem. How do we deal with a problem for which there is no “cure”?
Initial treatment is non-operative management, which will work for many. However, since there is no cure, we are not using these non-operative options with the expectation that we are curing arthritis or are going to have a normal knee. I think we should look at these options as ways to allow us to continue to have an active lifestyle and be functional patients, albeit with occasional but acceptable discomfort, with the knowledge that over time the arthritis will progress. For some the progression is slow and steady. For others itʼs slow but with peaks and valleys, or “flare-ups” followed by times of improvement. For others yet it is a more rapid progression. Unfortunately we do not know how arthritis will progress for each individual. We simply have to observe what happens. Non-operative management includes:
- Tylenol or acetaminophen - Doses of around 3,000 mg per day (usually 1,000 mg at a time, 3 times a day) can be effective and seem to be relatively safe even with longer term usage.
- NSAIDʼs (such as ibuprofen or Advil, naproxen or Aleve) - These are a mainstay and may also be used fairly regularly at appropriate doses, but can cause heartburn or GI ulcers, and with longer term use things like kidney function should be monitored with blood work.
- Neutraceuticals or vitamins/supplements - There is some evidence that certain vitamins can help with arthritis pain. There are also studies that show no difference vs placebo. There are several different kinds and even more different doses. I do not feel there is a right answer for everyone on this. There are patients who feel like they get very good relief, others who feel no difference, and still others who do not feel like they help but then have worsening pain when they stop. My opinion is that there are very few side effects for most vitamins (nausea and stomach upset are the common ones), and they are worth a try if you are interested. Some vitamins that have shown possible benefits are glucosamine/chondroitin (~1,500 mg), CoQ10 (~200mg), Omega 3 fatty acids (~450mg, specifically of DHEA and EPA), and possibly tumeric or what is felt to be its active ingredient curcumin (~500mg). Recommendations are to try high quality brands, preferably that have had independent lab testing to verify the accuracy of their ingredients.
- Weight loss - Your knees feel a 3:1 weight ratio, so loosing as little as 10 pounds can make your knees feel like they are carrying 30 pounds less. This not only helps with pain but can help slow progression of the disease.
- Physical therapy - Appropriate exercises (usually low impact exercises that incorporate many muscle groups together) can help strengthen your knee, help with your gait or how you walk, and help mobility. All of this can help improve your function, and decrease pain from an arthritic knee.
- Braces - Numerous different braces are available, almost as numerous as the opinions about them. While braces do not help everyone, some patients do feel improvement in pain, and even feel more stable or secure with braces.
- Activity modifications - Simply avoiding aggravating activities or positions are simple steps that can help some. Heat or ice are also options that help some, especially at the end of the day. Walking supports such as a cane or walking stick in the opposite hand can help. Some have had improvement with acupuncture or magnetic therapy.
- A work horse for arthritis treatment are injections. These can be broken down into 3
- Steroids (aka cortisone) - There are many different kinds of steroids available. All work to decrease inflammation and help pain. They do not cure arthritis. Any injection carries the risk of infection or bleeding, which are rare but can be serious if they occur within a joint. While overall they are safe with very low risk of side effects, some people could notice skin discoloration, soft tissue atrophy at the injection sight, possible tissue weakness that could predispose to rupture (a real concern if injected into tendons/ligaments), and even rarely mood swings, hot flashes, agitation, or vaginal spotting. Due to concerns over long term potential for damage recommendations are that these only be performed 3-4 times per year, so we try to space these out at least 3-4 months.
- Viscosupplementation (aka rooster comb, gel, lubricant shots) - Again, there are many different kinds. All basically have the active ingredient of hyaluronic acid. This is a normal “building block” in your joint cartilage. Again, these do not cure arthritis, and there is really no strong evidence that they will even slow disease progression. They are also usually only indicated for mild to moderate arthritis, and some insurance carriers will not approve them for more advanced arthritis. They again carry very low risks since they are a procedure, but these are overall considered safe with a low risk of problems (some studies have suggested higher complications in that they usually show a higher incidence of pain associated with the injections).
- Biologics (aka stem-cell, platelet rich plasma, PRP, etc) - This is a new and exciting but also highly variable and unknown field of therapies. My opinion is that these options have potential to be treatment options, but as of now this is considered experimental. Most insurance companies will not cover them. There are a lot of variables to these treatments that I donʼt feel like we have completely mastered so that it can be applied safely and consistently to patients across the spectrum of arthritis. But it is an active field with a lot of ongoing research, and I think certainly holds promise and potential in the future. There have been several recent studies to suggest that things like PRP are at least as good as some of the other options like steroid or viscosupplementation.
When appropriate non-operative measures fail to give relief, the next step is surgical treatment. There are different options for knee arthritis, depending on severity, symptoms, location, size, and associated factors such as age and activity level. This decision making process is best approached as a team between you and your surgeon so that the best option can be chosen for each individual.