In part I, I explained the pathology of knee osteoarthritis (OA), as well as risk factors and diagnosis. In part II, I will discuss recommendations and treatment options.

Recommendations are as follows:

Weight loss (for overweight or obese individuals): Obesity is the single most important modifiable risk factor for OA. For every one pound of weight you lose, it lessens the force through your knee by four-fold with every step.  Many studies have also shown decreases in pain ratings after patients lose weight. In my mind, the human skeleton is simply not meant to withstand the force of carrying excess weight. The fact that 66% of Americans with osteoarthritis are obese supports that.  Sadly, 1/3 of Americans are obese or overweight, and this number continues to grow.

Activity modification: if you are a runner and carry the diagnosis of OA, it’s probably time to hang up your running shoes. That being said, there is not a clear-cut association between high volume running and the development of OA. However, studies suggest that lower impact activities (swimming, exercise bicycle) are more beneficial than higher impact activities (running, high impact aerobics classes) in terms of symptom management. I am often asked about walking for exercise. My answer is this: if walking is your only form of exercise, then please continue. I’d rather you walk than do nothing. However, if you have access to an exercise bike or a pool, those are better options. “What if I don’t like to swim?” That’s okay – even if you only get into the pool and walk back and forth, that activity is better than nothing. At the end of the day, the answer is to stay active! The less you do, the more stiff and painful the joint will become.

Strengthening: I always recommend physical therapy and/or a good home program of quad (thigh muscle), hamstring, and core strengthening. It makes a big difference, especially to those who complain of difficulty getting up out of a chair or ambulating stairs. Physiologically speaking, the quad muscle tends to slowly atrophy over time secondary to knee pathology. Also, studies have shown improvement in pain and function scores with strengthening programs.

Medications: both acetaminophen and anti-inflammatory medications, such as naproxen or ibuprofen, are recommended for pain associated with osteoarthritis, and they can be bought over-the-counter (OTC).  If you cannot tolerate anti-inflammatory meds, for example due to reflux disease or aspirin allergy, acetaminophen is a good option, as it has less gastrointestinal (GI) side effects. Topical anti-inflammatory medication can also be considered. Be sure to follow recommended dosing on the bottles of these medications in order to avoid kidney or liver damage. Patients commonly ask if ibuprofen is better than naproxen or vice versa. Unfortunately, there’s not a good answer for that, in terms of efficacy. What works better for me may not work as well for you.

Your physician may also prescribe stronger anti-inflammatory medications, but it is unwise to take these for a long period of time. There are gastrointestinal and cardiovascular risks associated with these medications. I’m commonly asked about Celebrex, which is an anti-inflammatory medication. It is different, however, because it was formulated to have less gastrointestinal side effects (GI bleeding, etc.) compared with the other anti-inflammatory meds. It does have the same cardiovascular side effects, however. I always advise that patients take any anti-inflammatory medications with food to decrease GI symptoms. I also recommend discussing risks vs benefits with a doctor if a heart or other cardiovascular condition exists.

Ice vs heat: ice is a good treatment for pain and swelling associated with OA flares. If you work out or go on a long walk and have pain and/or swelling afterwards, use ice. Fifteen to twenty minutes at a time will suffice, and longer periods of time may result in injury to the skin. Heat is beneficial when the joint feels stiff, for example in the morning.

Injections: I save cortisone (steroid) injections for the really bad cases of inflammation, when a patient has extreme pain and a lot of swelling. According to the literature, the average amount of pain relief is 2-3 weeks, but I’ve seen variations of this time frame in both directions. Unfortunately, these injections lose efficacy over time, and recent evidence suggests that the numbing medicine we use with the steroid injections may be detrimental to the cartilage. Human studies are needed to be sure, but it’s worth mentioning. It’s also important to remember that there are risks involved with any injection: infection, bleeding, increase in pain, neurovascular damage, and steroid flare, just to name a few. Folks with high blood pressure or diabetes can see an increase in their blood pressure and blood sugars for up to 7 days after a steroid injection.

Another type of injection is viscosupplementation or hyaluronic acid. The osteoarthritic knee has less hyaluronic acid than the normal knee, so the purpose of these injected materials (which are synthetic) is to temporarily replace the hyaluronic acid, giving somewhat of a lubricating effect, although the exact mechanism of pain relief is not completely clear. You may have heard of these as “rooster comb” injections because that is how they are derived. They do not replace or regrow cartilage. They do not slow the progress of osteoarthritis. They are indicated for pain relief only. Unfortunately, it is difficult to predict the length and amount of pain relief a patient will get from these injections. The literature reports average pain relief of 5 to 13 weeks, but again, this is highly variable in my experience.

Glucosamine: This is a supplement that is thought to regulate inflammation and cartilage degradation. It is sold in the US in many forms, and is thought to be relatively safe. The literature does not strongly support its use, although current dosing recommendations, as well as the formulation available in the US, have been called into question recently. Perhaps studies with higher doses will prove to be more beneficial.

Platelet-rich plasma (PRP) injections: Briefly, this involves taking the patient’s blood, spinning it down to separate out the platelets, and injecting them into the affected joint. Platelets are known to be rich in many different types of growth factors that promote healing and tissue repair. More research needs to be done in this area, but so far studies have shown some promise. Unfortunately, this type of procedure is not covered by insurance.

The only real “cure” for arthritis is a knee replacement. That is the final treatment. Obviously, there are many conservative steps in between, and replacement surgery is nothing to take lightly. There are risks, complications, and post-operative rehabilitation to consider. It’s also important to note that obese individuals have poorer outcomes and more complications with replacement surgery.

Still have questions about knee osteoarthritis? Do you have knee pain, but you’re unsure of the diagnosis? If so, please leave a comment so I can address future posts accordingly.