Non-operative Treatment of Osteoarthritis (OA) of the Knee
Christos Kondogiannis & James Stoney
Non-operative Treatment of Osteoarthritis (OA) of the Knee
Obesity is a risk factor for the development of OA.
- Carrying excess weight is associated with progression of osteoarthritis and increased pain.
- Studies of overweight patients with knee OA have shown that modest weight loss (< 5 kg) has significant short-term and long-term reduction in symptoms of OA.
Inactivity due to pain leads to reduced muscle bulk around the arthritic joint and joint instability. The aim of exercise is to reduce pain and disability, by strengthening muscle, improving joint stability, increasing the range of movement, and improving aerobic fitness. Other theoretical benefits include, weight reduction and improved general health. A number of studies have shown improvement in the symptoms of arthritis with a home-based physiotherapy program.
Regular light exercise is beneficial for knee osteoarthritis.
- The best exercises are walking, swimming and cycling.
- Golf and bowls should be well tolerated.
- Impact activities, in particular running and ball sports are not usually advised for patients with knee osteoarthritis.
Many people enjoy swimming. Water based exercises can be a gentle start in encouraging exercise.
- Water soothes painful joints.
- Water supports weight and makes exercise easier.
Lifestyle and Workplace Modification
Think about your workplace and home. Are there any modifications that could be made to reduce stress on your knee?
Larger companies may have access to Occupational Health specialists who can assist in providing a more suitable working environment.
Think about your activities at home and on weekends. Are there any that cause particular problems for your knee? Can you adjust the way you do things to decrease your knee symptoms?
- A walking stick can reduce load across the joint
- Shock-absorbing footwear with good side-side support, adequate arch support and heel cushion will reduce impact on the knee.
- Heel wedges may reduce pain related to uni-compartmental arthritis.
- Applying adhesive tape to the patella can provide relief in patellofemoral OA.
- The use of a tube-like knee support or bandage can give symptom relief
- When there is significant deformity, a structural brace can correct alignment and reduce pain, although these braces are expensive.
Applied carefully, improves pain threshold, decreases muscle spasm, reduces any associated inflammation. Ice is best used after exercise to reduce inflammation.
Applied carefully, can improve pain threshold and increase blood flow to “washout” pain stimulating chemicals. Heat is best applied before exercise to warm up the joint.
Self help groups
The Arthritis Self-Management Program is a community-oriented, peer-led program in which patients receive education and gain skills for self-managing the consequences of arthritis. The Arthritis Foundation of Australia coordinates the running of these courses, which are led by trained volunteers and held in community halls.
It is widely accepted that paracetamol is the oral analgesic of first choice and, if successful, should be taken long term. It is mild, generally well tolerated and safe.
(Naprosyn, Voltaren, Orudis, Mobic, Celebrex, Brufen, Indocid, Feldene etc)
These are effective in reducing the pain of osteoarthritis although there are a number of potential side effects: -
- Stomach irritation and ulcers. These may manifest as heartburn, reflux, stomach pain, vomiting, black bowel motions
- Anti-inflammatories may cause deterioration in kidney function, fluid retention and high blood pressure. There may be an increased risk of heart attack.
They are best taken intermittently or for short courses (i.e. about 3 weeks).
Glucosamine and Chondroitin
Glucosamine and Chondroitin are components of the articular cartilage of normal knees. They are reduced in osteoarthritis.
Some studies have shown that Glucosamine and Chondroitin tablets are able to reduce some of the symptoms associated with osteoarthritis. The combination of the two may be better than either alone. Successful studies have used 1500mg of glucosamine a day. Benefit may take up to 3 weeks to become apparent.
A number of independent studies have found that these products provide no real benefit. There are no studies that prove they restore worn out articular cartilage. These products must be regarded as unproven.
They are available without prescription from pharmacies, health food stores and supermarkets. There are no known side effects, but some preparations are derived from shellfish.
These are stronger painkillers for more severe pain. The most common opiate we use is codeine, which is often used in combination with paracetamol (i.e. Panadeine and Panadeine Forte). Some of the stronger Opiates are Tramadol, Endone and Oxycontin.
If the osteoarthritis is requiring regular strong painkillers then surgery may be indicated.
They have many side effects but allergies are rare.
Side effects include Nausea, Vomiting, Dizziness, Sleepiness and Constipation. Rarely, Tramadol may cause seizures.
Injections of cortisone into the knee joint can provide some people with a reduction in knee pain.
Some patients have a dramatic and sustained response, but unfortunately some people gain little or no benefit from these injections.
Some people have a cortisone flare and experience increased pain for several days following the injection.
Hyaluronic Acid Injection (e.g. Synvisc)
Hyaluronic acid is a component of normal joints. This has been shown to decrease joint osteoarthritis pain. Hyaluronic acid can be given as a weekly intra-articular (into the joint) injection for 3 weeks. Unfortunately it is expensive (about $500) and does not work in everybody. There is a small risk of introducing a knee joint infection with any joint injection.