43 million Americans have some type of arthritis. Arthritis is damage and thinning of joint cartilage. Cartilage is found on the ends of almost all bones. It is the glistening surface that allows the joint to move easily, with little or no friction. Generally, how much arthritis hurts depends upon the amount of cartilage that is lost. The pain occurs because the joint lining (synovium) becomes inflamed and irritates the knee and also because bone is rubbing on bone.
Arthritis is usually progressive – once you have it, it gets worse. How quickly this happens, and how much pain it gives, is different for each patient.
Types of Arthritis
The word “arthritis” is a catch-all term. Generally, there are two cause of arthritis:
- Osteoarthritis – By far, this is the most common type. Its common name is “wear-and-tear arthritis”. In most cases, the cause is unknown. There are some known causes, usually due to a long-term childhood problem, after trauma, or with loss of blood-supply to the bone.
- Rheumatoid disease and similar systemic problems (gout, lupus, psoriasis, ankylosis, and others)) also cause arthritis of the joint, resulting in cartilage destruction
A Quick Knee Anatomy Lesson
The knee is a hinge-type joint where the lower end of the femur (thigh-bone) meets the upper end of the tibia (shin-bone). Also involved in the knee joint are the patella (knee-cap) and the fibula (long bone that runs alongside the tibia on the outside of the leg). The kneecap is embedded in the very strong quadriceps muscles (“quads”) that help straighten and bend the knee. The knee is held together by very strong ligaments on the inside and outside parts of the knee, and within the knee joint itself.
Causes of Knee Pain Other than Arthritis
Even more common than arthritis are soft-tissue problems about the knee. These include:
- Bursitis / Tendonitis – Inflammation can occur in many spots around the knee and cause pain and swelling.
- Meniscal Cartilage Tears – Besides the articular cartilage that is usually involved with arthritis, knees also have a second type of cartilage called meniscus. The meniscus is an important “shock absorber” of the knee. Each knee has two of them. These tear most commonly with a twisting injury, but tears can also occur with normal activities. They are a very common and an important cause of pain. Their treatment can be different form that of arthritis. Pain from a meniscal tear needs to be differentiated from pain from arthritis. Very often, patients have both and solving pain from one may not solve pain from the other.
- Patello-Femoral Problems – The knee-cap itself can very commonly cause pain, especially when it does not track properly in its groove, there is muscle weakness, or “softening” of the cartilage.
- Ligament Injuries – Ligament injuries commonly occur in athletes and can cause pain and feelings of “giving-way” in the knee.
- Broken femur / tibia – Can happen in the elderly, but also in athletes and in trauma situations
Knee Arthritis Pain Characteristics
The most common pain associated with knee arthritis is medial pain (“inside” part of the knee). Certainly, arthritis can also hurt elsewhere around the knee including the lateral (“outside”) part, the front of the thigh, under the kneecap, and in the back of the knee.
Pain is usually most with activity, but as arthritis becomes more severe, pain can be present at rest or even keep a person awake at night.
Pain in the buttock, or going down the back of the leg is most commonly caused by a spine problem. It is very common to have knee arthritis and back arthritis at the same time and Dr. Mathews may want to differentiate between the two with other special x-rays or examinations. The same applies for hip arthritis. Hip arthritis can occasionally give pain down the front of the leg, toward the knee. This type of pain may need to be explored further.
Other Common Findings with Knee Arthritis
- Swelling – The irritated knee very often produces fluid, which can build up and is easily visible.
- Stiffness – The gradual loss of cartilage causes the knee to become stiff. As time progresses, it can even lose more motion and not straighten or bend fully. This has a tremendous impact on function.
- Limp – Arthritic patients will notice that they have developed a limp. Very often, family members and friends will notice it even before the patient does!
- Bowed-legs or “knock-knees” – This occurs due to the loss of cartilage on one side of the knee, causing the knees to curve out or in. The normal knee is slightly “knock-kneed”.
“Noises” – Bone rubbing on bone can occasionally make unusual noises.
- Difficulty with activities of daily living – Patients with knee arthritis specifically complain about an inability to do the things they “used to be able to do”. This is a very important reason for seeking out treatment, as today people are living longer and enjoying activity into their nineties and even older. Common complaints are trouble with stairs, difficulty getting in and out of chairs, decreased walking distances, and even loss of sleep.
Treatment of Knee Arthritis
Unfortunately, once it’s lost, our bodies cannot re-grow cartilage of the same caliber. Research is heading this way, and some cartilage transplantation and re-growth treatments exist, especially about the knee, but only for very young patients with small areas of cartilage loss. These are in development stages and may one day within the next century become primary treatments for all patients. For now, treatments that control the pain and inflammation (especially in patients with mild or moderate arthritis) are our only way of treating patients without surgery.
- Taking it easy – It is important to remain active, as the benefits on the heart and lungs greatly outweigh any arthritis problems. Scientific studies have shown that active people have a better general well being and better results. But, be easy on your knee. When you have a choice, take a car, instead of walking. Use an elevator instead of stairs. Use a cart when golfing. Play doubles tennis instead of singles. Picking “knee-friendly” activities can help you maintain an active lifestyle. These include “weightless exercise”, such as swimming, and pool therapy. Bicycle use is better than long-distance walks or running. Avoid impact-type activities. Try not to overdo it if you are having significant pain.
- Heat and Cold – Use heat before exercise, for warming up. This helps to improve motion and increases circulation around the knee. Use a cold pack or ice after exercise or when the knee is inflamed. This can help decrease swelling and inflammation, and also helps with pain.
- Cane – Canes help take weight off the arthritic joint. Ask your doctor to draw the physics diagram that shows how a cane can help you – and why you should use it in the opposite hand.
Losing weight – Some parts of the knee may see 3 – 5 times your body weight with every step. So if you weigh 200 lbs, that hip joint can see ½ ton of weight (1,000 lbs) every time you take a step! Scientific studies have shown that weight loss helps with arthritis pain. Exercise is painful with arthritis, but with a good diet and medication regimen, and knee-friendly exercises, many patients are able to cut down on their weight.
- Physical Therapy – Therapists can often help by strengthening the muscles about the knee joint. This helps take some of the stress off the joint itself, and thus help with pain. In addition, physical therapy includes “modalities”, such as ultrasound, which can help with inflammation and pain about the knee.
- Medications – These pills are not only painkillers, but they help with inflammation! – So they help with pain in two ways. Unfortunately, they don’t cure or slow down arthritis. There are many options:
- Over-the-Counter – (Aspirin, Bufferin, Advil, Motrin, Ibuprofen, Aleve) These are easy to get, and safe, especially if you follow the directions on the bottle. They are helpful for many patients with arthritis.
- Tylenol – By itself, this is not an anti-inflammatory medicine. It is an analgesic (pain reliever). So it can be safely taken with the others, and is a great way to add to pain relief.
- Prescription Anti-inflammatories – (NSAIDS)(Naprosyn, Voltaren, Clinoril, Feldene, dozens of others). These are the most commonly used second-line medications, for those patients who do not get relief from the over-the-counter medicines. If one doesn’t work, there are many others to try.
- Newer Prescription Anti-inflammatories (COX-2-specific)(Celebrex) – These protect the stomach more and are commonly used medications
- Major Occasional Anti-inflammatory Side-Effects
- Stomach irritation / Stomach ulcer – Ulcers and gastritis can cause bleeding and be life threatening – so if stomach pain, vomiting, or black stools develop, stop them and call your doctor immediately
- Easy bruising, bleeding – These medications can cause some thinning of the blood, and you may notice easy bruising. Also, they must be stopped several days before surgical procedures.
- Increased blood pressure – Celebrex has been shown to rarely cause increased pressure and/or leg swelling
- Sulfa Allergy – Patients with Sulfa allergy cannot take Celebrex.
- If on one of these medications for more than 3 months, you need to let your medical doctor know – he needs to do special tests for your liver and kidneys every few months
- Try not to smoke, drink alcohol excessively, or use cortisone if on one of these medications or if on Tylenol\
- You will be unable to take these medications without your medical doctor’s OK if you take blood pressure pills, aspirin, diabetes medicines, diuretics, digoxin, lithium, blood-thinners, phenytoin, methotrexate, barbiturates, or certain herbal medicines.
- Creams – These substances have been shown to have some pain-relieving effects. They can take weeks to work and often need to be applied several times per day. They can be helpful in combination with other treatments for patients with mild arthritis.
- Glucosamine / Chondroitin Sulfate – These supplements are currently very popular. Science is not sure how they work. They are “natural” substances that can be found in the human body. The ones that are sold in the store are made from animal products (crab, lobster, shrimp shells)(tracheas, shark cartilage). These supplements may help with pain, although recent studies are not clear. Studies have shown them to be safe.
- Recommended doses: Glucosamine 1500 mg and Chondroitin 1200 mg daily
- Ask your doctor or pharmacist for a well-trusted brand with a reliable doses
- Make sure it has a reasonable price – Be careful about how many pills you get, and the doses!
- Cortisone injection – Cortisone is very helpful in knee arthritis. Access to the knee with a needle is simple and done quickly right in the office! The procedure is minimally painful and can give great relief. These injections can be given many times, but need to be spaced out by 3 months. As arthritis gets more severe over time, injections become less useful. It will not change the fact that the cartilage is gone.
- Joint fluid supplements (“lubricants”) (Supartz, Synvisc, and others) – These are a short series of injections that are given weekly. They are very popular in the news today and are used quite often in our office. The procedure is minimally painful and can give great relief. They are “natural substances” which are made from rooster combs. Their mechanism of action is not clear, but some patients do benefit from them.
- Bracing – Regular knee braces have not met with much success in the treatment of knee arthritis. However, occasionally pain relief can be obtained with an “unloader” knee brace. This slightly alters the mechanics of the knee, taking some stress off the more arthritic areas.
- Shoe Wedges – Occasionally, slightly altering the mechanics of the knee by placing an angled wedge under the heel can help with arthritis pain. Although it takes some getting-used-to, the pain relief can be significant.
- Alternative / Complimentary Medicine – Acupuncture and massage have been shown to help patients manage the pain associated with arthritis, and certainly are relatively safe options for the patient with mild arthritis of the knee.
- Osteotomy – This is an operation to realign the bones of the knee and change the mechanics in patients with early arthritis, thus taking some of the stress off the more arthritic areas. Today, this operation is much less common, although it can help in the appropriate patient.
- Arthroscopy – The role of arthroscopy for knee arthritis has been in the news lately. Over 1.5 million arthroscopic knee surgeries are performed yearly in the U.S. “Cleaning out” the knee joint with a small arthroscopic surgery can help patients tremendously, especially if they have loose particles or cartilage. The procedure is small and short, and the recovery is very quick. If there is another problem in the knee, such as a meniscal tear, arthroscopy can alleviate the pain associated with this problem. The combination of arthroscopy and physical therapy, as well as the above-mentioned treatments, can be very successful for arthritis pain. Arthroscopic techniques to help “save” the knee are evolving, and procedures now exist that may help restore cartilage defects in the knees of appropriate patients (Carticel, OATS). You may be a candidate for one of these procedures.