The purpose of this website is to increase your understanding of degenerative arthritis of the knee and provide information concerning the various care choices.
In the past, people met in physical places as in doctor's offices and clinics. However, today via the Internet, the meeting place may be otherwise, as our logo depicts The Place in CyberSpace™. You are now in The Place in CyperSpace for information about knee joint arthritis.
In time, we will facilitate an opportunity in The Place in CyberSpace™ for participants to ask questions of our medical staff and also chat with one another concerning matters of mutual interest.
It is our goal to make this a real place for the study and care of people with arthritis of the knee.
Very simply stated, degenerative arthritis is a "wear and tear" type of arthritis. However, research has shown there is an inflammatory, enzymatic, genetic basis as well as mechanical component.
There presently is no known cure. Therefore, the treatment measures taken are intended to decrease the symptoms or halt the progression of the arthritis. These measures are called palliative. Palliation means to relieve or lessen without curing. In other words, the treatment is aimed at decreasing the symptoms, even if temporarily. The following educational perspective addresses the various options to manage the symptoms of degenerative arthritis of the knee.
Background: Knee joint arthritis typically develops over a long time and gradually becomes progressively worse. It is known that the later in life one experiences an injury as the cause, the shorter period of time for arthritis to develop. A young person may take several decades to develop significant symptoms of arthritis following an injury. Degenerative arthritis with a genetic basis gradually worsens over a long period of time.
Since the onset of knee joint arthritis is usually gradual and the major symptoms are often years later, there are a variety of considerations for management of the condition in the meantime.
You may continue reading through all the information on this site or selectively link to the section which addresses your specific arthritic knee problem. You probably are in one of the following categories due to your knee arthritis. Pick the proper category and the link takes you to the information specific for your condition. You may skip this choice and continue reading general information.
Please choose one of the following concerning your knee arthritis.
Surgery
Total Knee Replacement: Perhaps you have been told that when the arthritis gets bad enough to come back and "we" will do a total knee replacement. Why this approach? Although there is evidence of even significant arthritis, the decision to have surgery should be made based upon the nature and the severity of the patients symptoms. Since there is presently no known cure for degenerative arthritis, the treatment is what in medical terms is known as palliative, as opposed to curative. This means the treatment is intended to reduce the symptoms or delay the natural process rather than cure the disease. A number of palliative treatments may be helpful; pain medicine, arthritis medicine, joint injections, exercises and weight loss.
Ultimately, patients often require a total knee replacement operation. This is a major procedure and not without complications. There may be infection, loss of motion, and even loosening of the artificial joint. The longevity of a total knee replacement may be 10-15 years and then may have to be repeated. The results of the second operation are usually not as good as the first. Therefore, surgeons exercise prudence before recommending such a procedure until it is absolutely necessary. The absolute necessity occurs when the patient can no longer do what they need to do or want to do. Even the best outcome from a total knee replacement does not return the patient to sports, but the expectation is to have pain free activities of daily living. Total knee replacement is not a cure but a reasonable management alternative when indicated.
So the question becomes, is it possible to do something short of total knee replacement to maintain the activities of daily living?
In most cases, the answer is yes. The treatments will not cure the arthritis but perhaps reduce the symptoms so as to avoid a total knee replacement or at least delay such a decision.
So how does one cope with the discomfort as well as deformity, loss of motion, and activities? What does one do to get along in the meantime until it is bad enough to consider major surgery? The following choices are made with the advice of a health care professional.
Arthroscopic photograph of inside the knee joint showing worn surfaces on top which is the end of the thigh bone and cushion cartilage (meniscus) eroded.
Arthroscopy is a surgical procedure performed through small portals with miniature instrumentation while viewing the inside of the knee joint via a telescope type lens with the images projected on a video screen.
Arthroscopy for degenerative arthritis of the knee has been widely publicized as an ineffective treatment based upon one scientific publication.
Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP, A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee; New Eng J Med 347(2) 2002: 81-88.
This article produced considerable controversy. It attracted legitimate criticism of both the methods and the interpretation of the study's results. Many professional reports have been written on this subject (see references below). However, some insurance companies have embraced this single article as a reason for non-payment for certain arthroscopic procedures for degenerative arthritis of the knee.
Most orthopedic surgeons believe that arthroscopy for degenerative arthritis of the knee is indicated if there is one or more of the following findings: swelling, inflammation, locking, torn cartilage and or evidence of loose bodies in the joint. Any one or all of these findings contribute to the progression of the inflammation which adversely affects knee joint arthritis. Surgical debridement or removal of the offending tissue will decrease symptoms. Absent any of these findings or the presence of severe loss of motion, marked instability or mal-alignment then arthroscopy is unlikely to produce a benefit.
Non-operative Alternative Treatment Methods
There are a number of non-operative treatment methods available. None of these will produce a cure. They are called palliative. Palliation means to relieve or lessen without curing. In other words, the treatment is aimed at decreasing the symptoms, even if temporarily. There are many publications concerning this topic. The following recent one is typical of what you may find in professional medical journals via an Internet search.
Hanypsiak B, Shaffer B. Nonoperative Treatment of Unicompartmental Arthritis of the Knee. Orthopedic Clinics of North America, Volume 36, Issue 4, Pages 401-411 B.
Categories of Non-Operative Treatment Methods
- Activity restriction
- Weight loss
- Muscle strengthening
- Pills
- Anti inflammatory non-steroidal
- Nutriceticals
- Vitamin D
- Knee joint injections
- Knee wraps
- Unloading braces
- Acupuncture
- Shoe Wedges
- Insoles
Activity restriction: It may be necessary but not very desirable as most patients desire a moderate to vigorous activity level. There are certain activities one learns by experience to avoid. Rough uneven terrain may produce symptoms so you may be limited to walking on level ground. You may have pain after doing gardening or yard work, especially digging holes or climbing ladders, so you stopped. You may find going up and down stairs or inclines bothersome. You may have moved to a one level home. Previous runners may take up walking or even swimming, as much as they do not want to stop running. Like most people, we want to remain active, but certain activities may have to be eliminated or modified.
Weight loss: It is known that weight loss will result in decreased symptoms of knee arthritis. Diets are a popular non-solution. A change in eating habits and life style change is the only permanently successful means to lose weight. This may be the least appealing treatment, but does work and is inexpensive.
Muscle strengthening: This is a very important measure since the pain will insideouly cause one to not use the involved extremity and muscle weakness will gradually happen. Therefore, prophylactic measures must be taken. It is important to be proactive in this matter.
Exercises may be instituted for muscles surrounding the hip, knee and ankle and can be a great benefit. This can be accomplished at commercial gym or with a physical therapist when convenient. It also may be done at home with inexpensive simple exercise equipment which is available for purchase on this website. However, it is recommended that exercise programs be under the supervision of a health care provider or by prescription.
Pills: Medication is typically developed by a pharmaceutical company. This industry is under careful Federal Food and Drug Administration (FDA) regulations.
Aspirin and acetaminophen (Tylenol®) are common anti-inflammatory and or pain medication for arthritis.
Non-steroidal anti-inflammatory medication like Ibuprophen (Motrin®) may be effective. It may be most effective when used intermittently and/or prophylactically during times of desired increased activity. They are not without complications, so careful attention to the labeling is important. Recently, two popular arthritis medicines potential complications were publicized.
The other source of "pills" falls under the name nutraceuticals. They are considered food supplements for regulatory purposes. The regulation has not been as strict as for pharmaceuticals. The regulations are not historically as strict in good manufacturing practices or quality control. In fact, many of these supplements have been shown lacking and even some with potential hazardous inclusions.
Nutraceuticals are not governed like pharmaceuticals by the Food and Drug Administration. Presently the FDA is requiring more quality control and safety for such products.
Glucosamine and Chondroitin sulfate: These alternative medicine pills may be helpful. The mode of action is not scientifically understood. The benefits and results of the use are controversial.
You may look at the following reports or conduct your own search concerning the effectiveness of these medications.
Vitamin D: Low vitamin D levels associated with knee pain, difficulty in walking. A recent study found that low levels of vitamin D may cause greater knee pain and difficulty walking in patients with knee osteoarthritis. The test included standard ways of measuring patient function like getting up from a chair and walking time with the vitamin D levels in their blood. A deficiency of vitamin D was associated with increased knee pain and a slower walking speed. (MedicalNewsToday.com) This may be a matter to be personally evaluated with one's health care professional. The presentation abstract can be found at: AbstractsOnline.com.
Knee Joint Injections: Hyaluronic acid injections may be helpful in some cases. Repeat injections are often necessary. At best the benefit is temporary and do not grow cartilage cushion or address any existing deformity
Cortisone injections are reserved for patients with end stage osteoarthritis of the knee. Cortisone may have deleterious effect on normal cartilage. These injections are often combined with drawing fluid off the knee. Cortisone injections may reduce the inflammation but the benefit is usually temporary and does not cure the underlying arthritic condition.
Knee wraps: Neoprene and other cloth based or elastic wraps are commonly used for knee joint pain or swelling. They are usually self prescribed and purchased at the drug store or supermarket. They may reduce symptoms. The biological effects or rationale are not recognized. It is unlikely that they in of themselves would be harmful.
Braces: There are a number of braces designed for arthritis of the knee. They are intended to decrease the load on the affected side of the knee. Not all are patient friendly and often are rejected due to bulky size or as being cosmetically unacceptable.
One brace that has favorable consideration is by
DonJoy. (DonJoy.com)
Acupuncture: Acupuncture is controversial. A study published in the August 15 edition of the British Medical Journal finds that there was no additional improvement in pain scores when acupuncture was added to a course of advice and exercise for osteoarthritis (OA) of the knee. Researchers examined 352 adults (94 percent follow-up) aged 50 or older who had a clinical diagnosis of knee OA. Participants were evaluated for a change in scores on the Western Ontario and McMaster Universities OA index pain subscale. At six months after baseline, reductions in pain (expressed as mean[standard deviation]) were 2.28[3.8] for patients who received advice and exercise, 2.32[3.6] for those who received advice and exercise plus true acupuncture, and 2.53[4.2] for those treated with advice and exercise plus non-penetrating acupuncture. The abstract of the study can be viewed at: BMJ.com
Shoe Wedges: Wedges on the bottom or sole of the shoe will alter the gait to reduce the forces transmitted to the knee joint. There are many papers published confirming the effectiveness of changing the gait in patients with medial compartment arthritis. We are offering a solution on this website for insoles.
However, the wedge is typically a hard material and provides no cushioning benefit. In addition the wedge is on the shoe's outer sole and contemporary shoes often have non leather composite materials in the sole that do not lend themselves to easy applications of such a wedge. The application also requires an orthotist or shoe repair person to modify the shoe at a considerable expense. An orthotist specializes in planning, making, and fitting orthopedic braces.
A cushioned sole on a sole like this seen on the FootJoy
® brand may be helpful in substitute cushioning especially if combined with an insole.
Shoes with Cushioned Soles: There are several alternatives for substituting for loss of knee joint cartilage cushioning, depending upon the nature and extent of the person's arthritis; shoes with cushioned sole or insoles. These should be used in combination with stretching exercises to limber the ligaments of the knee and or straighten the knee.
The use of shoes with a cushioned sole is a logical consideration. One such quality shoe is the spike-less golf instructor's shoe sold by FootJoy®. Although somewhat expensive, an Internet search may find this shoe at reduced price at closeout or blemished, but will serve the purpose.
Insoles: Insoles may be purchased at most drugstores or supermarkets. The quality is consistent with the low price. The insoles available at RxKnee.com are of high quality with specific designs for the person with various manifestations of knee arthritis.
DrLanny's Insole Construction: There is difference in quality of construction and materials in this more expensive insole. The insoles offered on this site are much better material than the typical foam rubber found off the shelf in drug stores and super markets. Equally as important, the material has greater wear properties when compared to less expensive over the counter inserts of foam rubber. Testing has shown that the absorption factor of DrLanny's Insole is up to 75% of any impact. This wonderful cushioning property found in DrLanny's Insoles substitutes for lack of cartilage cushion in the knee.
Very important is the physical property that the material returns to its previous shape immediately. This is called material memory. A simple test, illustrated below, shows that the material rebounds faster than normal tissue of the finger which remains compressed for few minutes.
The insole's material memory: Notice on the left photo, the compression of the wedge between the thumb and index finger. On the right photograph, the pressure is released and the insole returns immediately to its previous shape while, ironically, the index finger tissue remains compressed (arrow) and takes longer than the insole to resume previous shape.
3 Major Problems Accompanying Knee Arthritis
- Loss of knee range of motion
- Especially extension (straightening) which adversely affects normal walking.
- Loss of flexion or bending is a potential problem.
- Deformity of the knee
- Bowleg
- Knock-knee
- Few patients may maintain normal alignment.
- Loss of the cartilage cushioning effect in the knee joint.
Loss of Knee Straightening: The loss of knee straightening or extension may be the early result of knee joint arthritis. It may not be noticed at first as the knee often normally has minimal hyperextension (knee bends backward, the so-called double jointed). The early sign of a problem is the loss of the hyperextension while the knee still appears to fully extend. With time, however, the knee may not fully straighten. Loss of extension is most noticeable when one knee is involved and the other knee is not. To determine this early loss of motion, the person sits on the floor and puts both legs stretched out in front of them. The quadriceps muscles on the front of the thigh are tightened so as to draw the back of the knee down to the floor. The back of the normal knee will easily come in contact with the floor. The back of the knee lacking extension will not touch the floor. You may be able to slide your hand between the knee and the floor. The knee stays bent in spite of your best effort to straighten it. Even pushing on the knee will not result in the back of it touching the ground. If this is the case, you are losing motion in extension. We are offering a solution for this problem on this website.
Lack of Knee Flexion: To check for the ability to bend your knee, you may sit on the floor and bend your knee in an attempt to bring your heel to your buttock. Both knees should bend beyond 90 degrees easily and if you are real limber you will be able to touch your heel to your buttock. This is possible in youth, not necessarily normal in seniors. If you cannot bring your heel to within six inches of your buttock then you may lack knee flexion or bending. This varies with the patient's age and the girth of the thigh and calf which can block the knee flexion.
Important Consideration: The following methods are directed towards the effects of mild to moderate arthritis of the knee and in those people without major deformity or loss of motion. The alternative methods listed herein would be of little or no benefit those with severely limited range of motion or those that walk with a lurch, side to side. The latter is noticed if with weight bearing the deformity of the knee is exaggerated and the knee shifts sideways with each step.
Your Symptoms
Knee joint arthritis affects different people differently. Now that you have information concerning the various methods of treatment and you want to consider a non-operative alternative, please choose one of the following.
Please make one of the following selections that best describe how knee joint arthritis has affected you so we may direct you to the appropriate non-surgical alternative.
Painful knee, but no deformity
Pain on inner side of knee with bowlegs
Pain on outer side of knee with knock-knees
*Note: These concepts probably would not help a person with severe arthritis manifest with severe deformity, a very stiff knee with very little range of motion and/or a person with knee joint instability. A person with uncontrolled pain and or swelling should seek professional medical attention.
Alternative Health: This site and its products are an alternative health site and we are not nor do not intend to practice medicine, make a diagnosis and or render a treatment. The acceptance of these devices and methods is solely based upon your initiative, experience, knowledge of, and responsibility for your personal health.
References — Osteoarthritis of the Knee
The American Academy of Orthopedic Surgeons has released an opinion paper on various treatments of osteoarthritis of the knee. It contains valuable information representing a consensus of the committee. The document has not been subject to public input or that of minority opinions of the orthopedic community. It is worthy of your attention on the various modalities available today documented in the literature.
References — Arthroscopic Surgery Concerning Knee Joint Arthritis
- Bert JM, Maschka K: The arthroscopic treatment of unicompartmental gonarthrosis: a five year follow-up study of abrasion arthroplasty plus arthroscopic debridement and arthroscopic debridement alone. Arthroscopy. 1989;5(1):25-.
- Friedman MJ, Berasi CC, Fox JM, Del Pizzo W, Snyder SJ, Ferkel RD: Preliminary results with abrasion arthroplasty in the osteoarthritic knee. Clin Orthop. 1984 Jan Feb;(182):200-205.
- Rand JA, Ritts GD: Abrasion arthroplasty as a salvage for failed upper tibial osteotomy. J. Arthroplasty. 1989;4 Suppl:S45-S48.
- Blevins FT, Steadman JR, Rodrigo JJ, Siliman J: Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance. Orthopedics. 1998;21(7):761-767.
- Jackson RW, Dieterichs C: The results of arthroscopic lavage and debridement of the osteoarthritic knees based upon the severity of degeneration: a 4 to 6 year symptomatic follow-up. Arthroscopy. 2003 Jan;19(1):13-20.
- Hunt SA, Jazrawi LM, Sherman OH: Arthroscopic management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):356-363.
- Johnson LL: Arthroscopic Abrasion Arthroplasty Historical and Pathological Perspective: Present Status. Arthroscopy Journal. 1986;2:54-69.
- Johnson LL: Arthroscopic Surgery, Principles and Practice. St Louis, C.V. Mosby Co. 1986:737-773.
- Johnson LL: Arthroscopic Abrasion Arthroplasty: What is known and not known. Chapter 14.3 in Knee Surgery. Current Practice. Aichroth PM, Cannon, WD Jr. Patel, DV. Dunitz 1999:576-595.
- Richmond JC, et al: A canine model of osteoarthritis with histologic study of repair tissue following abrasion arthroplasty, Presented at annual meeting of the Arthroscopy Association of North America, Boston, 1985.
- Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP: A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee; New Eng J Med. 2002;347(2):81-88.
- Horowitz JM: Time. 2002 Ul 22;160(4):62.
- Johnson LL: A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. Arthroscopy. 2002 Sep;181(7):683-7.
- Burkhart SS: Do Statistics ever lie? Arthroscopy. Oct;818(8):823.
- Poehling GG: A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. Arthroscopy. 2002;18(7):183-7.
- Garrett W Jr.: Evaluation and Treatment of the Arthritic Knee. J Bone Joint Surg. 2003;85:156-157.
- Jackson RW, Ewing W, Ewing JW, Chambers KG, Schulzer M, Blacher RS, Morse LJ, Wray NP, Moseley JB, O'Malley K, Horng S, Miller FG: Arthroscopic Surgery for Osteoarthritis of the Knee. N Engl J Med. 2002;347:1717-1719
- Dervin GF, Stiell IG, Rody K, Grabowski J: Effect of arthroscopic debridement for osteoarthritis of the knee on health related quality of life. J Bone Joint Surg Am. 2003 Jan;85-A(1):156-7.
References — Wedge Insoles in Knee Joint Arthritis
Also see Fang MA, Taylor CE, Nouvong A, Masih S, Kao KC, Perell KL. Effects of footwear on medial compartment knee osteoarthritis. J Rehab Res Dev. 2006.43(4);427-434.
Perhaps the most convincing evidence of the dynamic benefit of a lateral wedge in patients with medial arthritis was the statement by Kerrigan, et al., "These data imply that wedged insoles are biomechanically effective and should reduce loading of the medial compartment in persons with medial knee osteoarthritis."
Kerrigan DC, Lelas JL, Goggins J, Merriman GJ, Kaplan RJ, Felson DT. Effectiveness of a lateral-wedge insole on knee varus torque in patients with knee osteoarthritis. Arch Phys Med Rehabil. 2002 Jul;83(7):889-93.
The Federal Government NIH is also interested in this type of treatment method and has funded research in this area.
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