Mr Luke Jones, consultant knee surgeon at Grosvenor Orthopaedic Partners, discusses conservative management strategies for the pain of knee arthritis.
Knee arthritis is an very common condition. Patients will complain with a combination of pain and restricted range of movement. There can sometimes be associated swelling. Examination will often reveal some muscle wasting around the joint as well as an inability to fully extend the knee and difficulty flexing.
Patients will describe a dull throbbing pain often focused medially or anteriorly on the knee that can wake them up at night, can stop them from walking significant distances and can disrupt their lives in terms of the things that they want to do, such as walking for pleasure or playing sport . Sometimes it will stop them from doing the things they have to do such as working or maintaining their home.
Under these circumstances it’s important to undergo a clinical examination, to have the story of your arthritis thoroughly interrogated and to undergo x-rays that will allow the diagnosis to be confirmed.
At this stage it would be very rare for a surgeon to recommend an operation in the first instance.
Conservative management strategies (this means options for managing arthritis without an operation) will then usually be instigated. This will normally be a multifaceted approach.
It is important that people with arthritis in their knee try and modify activities that make the pain worse. This often means changing from doing impact work such as running to using a bicycle as this reduces the forces that are placed across the knee joint. Similarly, keeping your body weight within a recommended level will dramatically reduce the forces across the joint. There are a number of different methods that can be used to keep your weight under control. Your surgeon will often be able to discuss these with you.
Physical therapy is also very important for reducing knee pain in those with arthritis and by optimising both the strength and the size of your quadriceps and hamstrings, the pain in the knee is reduced.
Alongside these strategies, your surgeon will ask you to use some simple anti-inflammatories or painkillers. One of the painkillers that has really transformed the management of arthritis pain is Etoricoxib, which is a selective Cox II inhibitor. It works in a similar fashion to ibuprofen, but has a much better side effect profile. Paracetamol can also be very effective in combination with Etoricoxib in the management of pain.
Patients with arthritis will often notice that the knee has changed shape and can go into a bow-legged position. Under these circumstances, bracing to offload the medial compartment of the knee can be helpful and there are some very new modern braces that can be effective in reducing pain by the use of braces. These do not need to be worn the whole time and can just be used during activity.
Once less invasive measures such as these have been completely exhausted, the next step is to consider having some injections into the knee. There are two main sorts of injections, those that help reduce inflammation and pain and those that are aimed at helping to rejuvenate the joint. Cortisone can be an effective injection into the knee because arthritis, as well as being degenerative, is often very inflammatory. It can provide patients with short to medium term relief. It is important to remember at this stage that the injection should be performed under ultrasound to ensure that it passes correctly into the joint. Repeated injections over a short period of time are not generally recommended, but it is certainly safe to have one or two injections per year if they help to manage your pain effectively.
Other injections such as hyaluronic acid can also be effective in selected patient populations, but the evidence for these is mixed and patients should not expect a miraculous cure to their pain. Unfortunately, in patients with established osteoarthritis of the knee, injections such as PRP (platelet rich plasma) and stem cells are very rarely indicated. There is very little convincing evidence that these can provide long-term relief, although the specifics of your condition should always be discussed with your surgeon or sports medicine physician in order to understand whether you’re a candidate for these novel and as yet unproven strategies.
There are further injections available such as Arthrosamid and these remain within the realms of research. It is likely that they will form part of a coordinated patient pathway in the future, although yet the details of these have to be determined.
My experience is that at least 50% of patients that come to my clinic can have their arthritis managed very effectively with these conservative strategies. It is important that you ask your surgeon to discuss these with you in some detail when you see them in the clinic.
If you are suffering from Knee pain, don’t hesitiate to contact Mr Luke Jones to book a consultation.
Consultant Orthopaedic Knee Surgeon
References :
