Conservative treatment is initially indicated for nearly all patients with knee arthritis, just as it is for hip arthritis patients, with surgery being reserved for those patients in whom conservative measures are no longer enough. Most patients have usually progressed through the spectrum of conservative treatment by the time they are referred to an orthopaedic surgeon, but it is important to be aware of the nonoperative options that can often suffice for months or years before pain and disability are significant enough for knee surgery.
Note that most of this chapter discusses knee arthritis. Some other knee problems, such as internal derangement with frequent painful locking, may need arthroscopy or more urgent treatment. That is discussed separately in the arthroscopy chapter.
Activity Modification
Many patients with mild arthritis of the knees cope initially by making simple adjustments to their usual activities, avoiding the things that aggravate the knee. It is important to maintain as much activity and joint motion as possible, but impact activities will aggravate arthritis. Running and jumping will often accelerate cartilage loss from the joint. Using an elevator instead of stairs and avoiding uneven terrain are helpful. However, there is significant evidence that remaining active and keeping the knee moving will prolong its life.
Many patients worry that they should give up walking or other low impact activities in order to try to preserve the knees, but a sedentary lifestyle actually will shorten the life of the knees, just as it will for the hips. The key is to focus on low impact activities, such as swimming or cycling. These are the best forms of exercise with arthritic knees as they do not require significant weight bearing across the hip joints. For patients who do not have access to a pool or a stationary bicycle, leisurely walking will also maintain knee range of motion, strength, and function.
Canes
A cane can be helpful for getting
around with a bad knee. Use the cane in the opposite
hand from the arthritic (or recently operated) side.
Canes or walking sticks are useful, particularly when the arthritis affects only one side. Some canes have multiple feet or prongs (e.g., a quad cane) to increase stability for patients with poor balance. It is important to use the cane in the opposite hand from the bad hip or knee. This allows you to lean away from the bad leg, taking weight off of it. Adjust the height of the cane so that the hand height rests comfortably along your side, preventing stooping or poor posture.
Weight Loss
As discussed in the chapter on nonoperative treatment of hip arthritis, significant weight loss for obese patients can make a dramatic difference, although in actuality, relatively few patients are successful in losing weight because arthritis limits their ability to exercise. Weight loss is probably the single most effective intervention the patient can undertake on their own. Increasingly, severely overweight patients (300+ lbs.) are turning to bariatric surgery (e.g., gastric bypass surgery) with promising results, although it remains a serious operation. For the average patient who is somewhat overweight, losing 20 lbs. or more can often at least improve their discomfort.
Weight loss is also important for increasing the life span of a joint replacement. Although in our practice we do regularly perform joint replacements for patients even over 400 lbs., it is with the thorough understanding that their joint replacements may wear out more quickly, and they are at increased risk for complications with surgery. Surgery usually takes longer and is more challenging for the surgeon when the patient is morbidly obese (body mass index > 35), due to the loss of anatomical landmarks, prolonged exposure and closure time, and need for additional assistants at the time of surgery. This is true for both hip and knee replacement surgeries.
Knee Injections - Steroids
Steroid injections into the knee joint and/or bursa (between the muscle layers on the outside of the knee) are usually quite effective, and may be all that is required in combination with physical therapy and antiinflammatory medications for resolution of a patient's symptoms. These injections do not require live x-ray, and the injection is usually administered over the side of the knee or from the front (along the joint line).
Occasionally, some patients may develop large effusions around the knee joint (e.g., "water on the knee"). This large fluid collection is an abnormally large collection of normal joint fluid in most cases, although effusions can also be seen with gout, pseudogout, trauma or injury, or infection. Patients usually feel much better when the fluid is aspirated (drained), and the fluid can also be sent to the laboratory for further analysis if needed. Many physicians will also inject the knee with corticosteroids at the same time after aspirating (as long as there is no suspicion for infection).
Injection therapies do not "cure" the underlying problems of arthritis, but can be useful for short term relief (potentially for a few months) and for diagnostic purposes. Injection of the knee joint typically is quick and only takes a few minutes in the office, and unlike hip joint injections, it does not require the use of a live x-ray machine (fluoroscopy) to ensure that the injection is placed into the joint itself. Most surgeons inject a local anesthetic and steroid mixture (contrast is not usually used, but it is employed for hip injections). The anesthetic will often make the knee immediately better and somewhat numb for a few hours afterwards, and then the local anesthetic wears off. The steroid component may take 5 to 7 days to fully take effect.
While injection of the arthritic knee joint itself is not a cure, it does have several very useful roles. It is very useful for diagnostic purposes to help determine where a patient's primary source of pain is originating from. Frequently patients may present with both knee and hip arthritis; prior to planning joint replacement, it is useful to see if their pain improves (even for just a short while) by injecting the knee. Another common scenario is that of a patient who knows that he or she needs a knee replacement but is looking for a few months of temporary relief (e.g., they are traveling, or have a daughter's wedding coming up, etc.). Most surgeons try not to use steroid too frequently as it does have some side effects (notably, weakening of the bones and tissues, and rarely, infection), but commonly surgeons will consider injections a few times per year to be acceptable.
Knee Injections - Hyaluronate
Steroid injections in the knee joint have been used for decades. A newer option is hyaluronate injection, which involves injecting a thick, clear gel into the knee joint that acts as a cushioning lubricant and antiinflammatory agent. The injections have many different trade names, depending on the manufacturer, but most are similar in mechanism and overall effect.
Commonly used hyaluronate injections include SynviscTM, SupartzTM, HyalganTM, and EuflexxaTM injections (all slightly different preparations from different manufacturers).
Hyaluronate, or hyaluronic acid, is a substance that occurs naturally in the joint. It is a viscous substance that normally lubricates the joint. Injections of large quantities of the material, obtained either from chickens or as a bioengineered product of bacteria (similar to the way that insulin is now manufactured), often decreases inflammation and makes patients feel better. In our practice, we administer hundreds of the injections each year, and generally about two-thirds of patients report that they feel better after the injections.
Benefits of the injections include a low risk of sideeffects. Repeated steroid injections can lead to serious side effects if they are administered too often, including osteoporosis. In contrast, hyaluronate injections have not been shown to have such effects, although a small percentage of patients may experience swelling. The most common downsides appear to be simply noticing no significant benefit (for patients with severe degenerative disease), cost (the injections are far more expensive than steroid injections), and the fact that most commercially available preparations require a series of weekly injections rather than a single injection. Typical series include weekly injections for 3 to 5 weeks with significant improvement usually taking about a month, and the injections can be repeated at 6 month intervals under most insurance plans and Medicare.
Given the cost of the injections, some insurance plans will not allow coverage for the expensive hyaluronate injections unless a patient has documented use of multiple anti-inflammatory medications, physical therapy, and previous steroid injection(s) that did not provide adequate relief.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
This family of medications includes aspirin, ibuprofen, naprosyn, and other non-narcotic medications to decrease inflammation. They remain the mainstay of preoperative management of arthritis pain and are usually most useful in the early years of developing arthritic pain for all joints.
Most patients experiment with different over-thecounter NSAIDs before finding the one that seems to work best for them. Older NSAIDs such as aspirin and ibuprofen have been around for many years, and newer drugs in this class called COX II inhibitors, such as celecoxib (Celebrex), valdecoxib (Vioxx - now discontinued), and meloxicam (Mobic) have recently been introduced. Many physicians feel that these are not much different from aspirin and ibuprofen in effectiveness, although these medications have fewer gastrointestinal side effects such as ulcers. For this reason these more expensive drugs are usually employed when a patient cannot tolerate traditional NSAIDs like ibuprofen, typically because of GI upset. Some of these drugs were in the news a few years ago (notably, Vioxx) because there was some concern about heart problems in a small number of patients. These drugs also require monitoring of liver function if taken for a long period of time.
It is important not to take NSAIDs on an empty stomach, or to use them with blood thinners (such as warfarin) unless directed by a physician. Collectively, these medications are responsible for many cases of GI bleeding and ulcers in elderly patients each year. These medications can interfere with kidney function and may lead to swelling in the legs. These medications can also interfere with some blood pressure medications, and it is important to also check with the physician prescribing the blood pressure medication before taking any of these medications.
Although orthopaedic surgeons may provide an initial prescription for a month or two of NSAIDs, it is usually preferable to obtain these from your family physician over the long term because of the need for monitoring after several months of use. Some of these drugs require monitoring and periodic blood tests after prolonged use.
Glucosamine / Chondroitin Sulfate
Glucosamine chondroitin is a "nutraceutical," essentially a supplement that is often found in the vitamin aisle of the drug store or supermarket. As such, it does not typically have to adhere to the same labeling rules as drugs that are regulated by the FDA, and it is not uncommon to see labels proclaiming that it will "re-grow cartilage!" There is not much evidence that it is likely to do anything so dramatic, although there is compelling evidence that it is relatively safe and works by decreasing inflammation in the joint, making at least some patients feel better. Patients with a shellfish allergy should use caution when taking this, as it may cause an allergic reaction. The typical dosage is about 1500 mg of glucosamine and 1200 mg of chondroitin sulfate daily. Most manufacturers sell the two mixed together in a single pill. It is not uncommon to have to take it for two weeks or more before a significant benefit is seen.
Narcotics ("Pain Killers")
Most hip and knee surgeons feel strongly that these do not have a role in the preoperative management of arthritis, and in our practice, we typically do not prescribe them except after surgery or fracture. Narcotics (such as oxycodone, hydrocodone, oxycontin, etc.) are useful for treating significant pain that is expected to get better in a few weeks. When taken for a long period of time, they can have serious side effects, including addiction, constipation, confusion, and a need for higher levels of narcotics to maintain the same level of pain relief. Additionally, patients who have been on narcotics for any significant time prior to surgery are typically much more difficult to keep comfortable after surgery because they have developed a tolerance to opiates (narcotics).
Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.
