Knee arthritis is often referred to as an inevitable part of ageing. Knee arthritis and osteoarthritis are more prevalent in older people but they can affect anyone. The majority of patients receive little treatment for this condition, jumping to a surgical solution when the condition reaches the bone on bone phase. Where cartilage remains the non-surgical treatments are particularly helpful. They can control pain and maintain activity levels for many years. Such treatments can benefit people of all ages.
How common is knee arthritis?
Knee arthritis is a common condition. According to Arthritis Research UK, 6.1% of people over 45 have knee arthritis that is severe enough to require treatment. That equates to over 9,112 people in Bristol and 150,303 in the Southwest of the UK.
What causes knee arthritis?
Knee arthritis is caused by inflammation and wear and tear of the joints bearing surface. The causes are usually multifactorial and thinking about the risk can be helpful:
- Age—the strongest association and 6.1% of those over 45 have severe knee arthritis requiring treatment
- Genes—arthritis can be more common in some families
- Gender—arthritis is more common among women
- Obesity—people with a BMI of more than 36, are fourteen times more likely to experience knee osteoarthritis
- Trauma and infection—an injury to the joint can cause damage to the knee and lead to arthritis
What can I do to help with the pain?
Knee arthritis causes pain, stiffness and reduced mobility. It reduces the quality of life and affects you in several ways.
- Keeping fit—obesity, cardiac risk and respiratory disease may be more likely if you are not mobile
- Socialising—Enjoying life and joining family/friends in more vigorous activities may be curtailed
- Work—25% of severe knee arthritis suffers who retire do so because of their knees
- Mood—poor health and poor mobility are associated with loneliness and depression
People suffering from painful knee arthritis fit into one of three categories
Conservative Treatments
Treatment Gap
Knee Replacement
Conservative Treatments
Symptoms controlled by conventional care management.
Treatment Gap
Patients where conservative treatment has failed but they’re not ready for knee replacement.
Knee Replacement
Symptoms only controlled by partial or total knee replacement surgery.
Clinical and economic consequences of the treatment gap in knee osteoarthritis management. London et al. March 2011. Medical Hypotheses 76(6):887-92
The treatment gap
15% of people over 45 years of age suffer from symptomatic knee arthritis. Despite participating in non-operative management programmes, one-quarter of this group find walking difficult. A significant number of arthritic knee sufferers will have difficulty walking. Family doctors (GPs), physiotherapists and surgeons can advise patients in the treatment gap. A broad spectrum of options beginning with non-surgical treatments and through to surgical procedures are available, before ultimately resorting to a knee replacement.
What is the treatment gap and am I in it?
If you have a disability due to knee pain despite treatment and have been told “your knee is not ready for knee replacement,” then you are in the treatment gap. The treatment gap is defined as the time spent between when the non-surgical treatment stops working and when your knee is suitable for joint replacement.
On average, the treatment gap straddles a period of 10 years, although, if arthritis onset is present at a younger age, then, it may stretch over most of a person’s adult life. 1% of the entire population is thought to be in the treatment gap. Consequently, in the Bristol area alone there are over 5,000 individuals for whom non-operative treatment has or will not deliver a satisfactory result and for whom surgery will not be an option.
Why has my doctor not booked me in for surgery?
Doctors are frequently asked “my knee seems to be heading for a total replacement. Why can’t we just get on and do it?” When the medical professional opts to first try a less invasive solution, patients are left with the impression that a lower-cost treatment is being sought or that the doctor is not convinced as to the severity of the ailment.
Why are surgeons reluctant to immediately recommend a knee replacement? The answer lies in the outcomes. Surgeons know that if a knee replacement is performed before bone on bone arthritis is present then fewer patients will be satisfied with the final result.
Historically, in these cases, partial knee replacements present a satisfaction rating of 95% whereas, total knee replacements come in at 70%. When performed on young patients with mild arthritis, this score drops to less than 50%. Surgeons will always seek to maximise patient satisfaction and for this reason, they may be reluctant to immediately suggest more radical procedures.
Managing my knee arthritis pain
Knee arthritis results in pain and stiffness. As the disease progresses, the joint gradually becomes stiffer and pain more intense. This may lead to night pain, joint swelling or leg deformity as the stiffness becomes ever more severe.
Until such a time when a knee replacement is possible, how can pain and discomfort be managed?
Despite claims to the contrary, frequently from dubious internet sources, modern medicine has yet to come up with a solution to reverse the arthritic condition. However, several effective treatments are available to control or eliminate pain.
How can knee arthritis pain be controlled or eliminated?
Subjecting younger patients to surgical procedures has proven not to be the best path. Effective non-operative treatments are the better option, though some of the more advanced treatments may not be offered by the family doctor. Addressing inflammation is a key element of treatment—symptoms of arthritis arise from a combination of mechanical irregularities and inflammation.
According to Arthritis Research UK, 6.1% of people over 45 years of age have knee arthritis that is severe enough to require treatment
26,481
people over 45 years of age in Bristol have some form of knee arthritis including osteoarthritis
9,112
people in Bristol have knee arthritis that is so severe that they would benefit from treatment
150,303
people in the Southwest have knee arthritis that is so severe that they would benefit from treatment
What treatments are available to me?
Knee pain can leave you less mobile and feeling less like yourself. If you’ve tried many treatments that haven’t worked, and you’re not ready for knee replacement surgery, then you’re in the treatment gap. It’s a bad situation to be in and one that can leave you feeling hopeless, but you do have options.
Pain killers
This is usually the first port of call. Most patients benefit from using appropriate doses of paracetamol, anti-inflammatory drugs (such as ibuprofen, naproxen, celebrex and aspirin) and opioid drugs (such as codeine, oramorph, tramadol and certain patches) over limited periods. These medications are not benign as some can have potentially serious side-effects, some are addictive and they may only be effective over short periods. Creams applied directly to the knee may also temporarily alleviate pain.
Neutroceuticals
This is an umbrella term for numerous dietary supplements including glucosamine, chondroitin, turmeric, cumin, grapes soaked in gin and any number of other treatments. CBD oil is also rapidly becoming a popular choice. Despite the abundance of studies, there is little scientific evidence to support these treatments as comprehensive solutions. However, on occasion, successful results have been reported and, as long as these do not create a financial or health burden, some doctors will not object to supporting patients in experimenting with these alternative medications.
Activity modification
Whereas some may find this helpful, others find they do not benefit greatly from the added exertion. There is no doubt that some exercises (squats, lunges, impact activities, rotation, tackling) are punishing on the knees. Other exercises may be kinder, such as swimming, cycling and rowing, among others. Building up from the less strenuous exercises to more adventurous levels may be the best solution.
Weight loss
Being overweight puts a huge amount of pressure on the knee cartilage. Some studies suggest that a 5% loss of body mass can result in a 50% reduction in knee pain. However, doctors acknowledge that exercise and increased physical activity can be difficult when experiencing knee pain and that unsupervised diets may only achieve temporary weight loss. Consulting nutritionists and bariatric surgeons is a path to a weight loss programme that will provide a sustained result. Exercises should be tailored to minimise knee pain whilst maintaining active.
Physiotherapy and exercise
It may seem very counterintuitive but increased physical activity, in this case, can be very helpful for certain patients. Physiotherapy can be hugely beneficial in treating stiffness and restoring a normal walking pattern. Exercises should be tailored to minimise knee pain whilst maintaining active, there are specific classes aimed at supporting people with arthritis stay active.
Osteotomy
This is a form of surgery that can be helpful where just one part of the knee is affected by arthritis, the pressure is transferred from the arthritic part of the knee through the unaffected area. This form of surgery can delay the ultimate date for a knee replacement. Correcting lifelong cases of bow leg or knock knee, can release the pressure on overworked joints.
Knee braces
A variety of knee braces can help with rehabilitation and can support the knee. Although immobilising the knee will weaken the muscles many modern braces will support activity enable a better range of motion and weight-bearing. Some can even pull the weight off the affected side offering some protection if one place in the knee is particularly painful.
Knee injections
Injections
Various injected therapies are available. In rare instances, these can cause complications, such as infections or allergic reactions. They differ greatly in their duration of efficacy and price. The effects vary between patients significantly, the information below is a guide only:
Steroid (aka Cortisone) injections
Typical duration: 3 months
These injections can be very effective for a = period. A first-time injection often provides pain relief for about three months. Further doses are usually less effective. The effects on the cartilage of the knee joint are not well understood.
Hyaluronic acid injections
Typical duration: 2-6 months
This engineered viscous fluid is similar to the natural joint lubricant and has been around since the 1970s. It was initially proposed as a shock absorber or joint lubricant but current thinking is that it may act as an anti-inflammatory agent. Some several recent systematic reviews support its use. Value for money is debatable and some insurers will cover the cost.
Stem cell injections
Typical duration: uncertain
This treatment has received an extensive deal of media attention and captured the imagination of pain suffers. A very expensive option; results are mixed and poorly reported; is it science fiction or a miracle cure?
Standard PRP injections
Typical duration: poor evidence
Research on the use of platelet-rich plasma (PRP) is patchy. In theory, PRP operates by injecting growth factor rich platelets from the blood into the joint. These treatments have proved to be more successful in treating conditions that require an inflammation to heal (such as tennis elbow) than those that are caused by inflammation (such as arthritis).
nSTRIDE® APS knee injections
Typical duration: 24 months+
nSTRIDE® differs from standard PRP (platelet-rich plasma) injections and you can read more about it on the dedicated nStride page. It differs from the stem cell injections in that it has passed rigorous testing by a major Biomedical company and has a favourable research base. The price point is also well below that of stem cell injections.
