Patient Guide for the Medical Non-Operative Treatment of Knee Arthritis
This guide is prepared by Frank R Noyes MD based on over three decades of treating knee arthritis in thousands of patients. This guide has many useful suggestions and guidelines for the safe and effective treatment of knee arthritis. However, the guide is not meant to be the only approach and patients are advised to be well informed and ask guidance from their primary care physician, pharmacy and other specialists.
Remember, every medicine has beneficial effects, but every medicine has “a little bit of poison” meaning side effects that need to be avoided if possible.
The overall goal is to select the safest approach with the least amount of medicine and side effects. Secondly to understand that the treatment of knee arthritis involves an entire program of rehabilitation, keeping active, weight control, possible knee braces and other treatments and it is not correct or beneficial to rely only on medicines.
For example, exercises are a major part of the treatment of arthritis and you should be under the care of an experienced physical therapist for a home program that is performed at least three times a week! Weight control is so important and for every pound you weight you place 3 to 6 times that amount on your knee joint in just walking or climbing stairs! With knee arthritis your activity decreases and your ability to burn calories taken in by your food also decreases so you need to adjust your diet and avoid high carbohydrate foods that put on weight.
USE OF ORAL OVER THE COUNTER MEDICINES
- These can be highly effective in the initial stages of knee arthritis. Use the common medicines you would use for a headache. Use only when the knee has pain and use for a day or a couple of days. This includes Tylenol, Advil or Aleve. Patients usually know which one works best for pain. Advil and Aleve are a class of nonsteroidal medications referred to as NSAIDS and are used in smaller doses to decrease pain and swelling. Make sure these medications to not upset your stomach and if you have any GI issues your family doctor should advise you on your medications.
- Combine the above low dose medicines with icing, activity modification, and some element of rest to allow the knee “headache” to resolve. Remember knee arthritis comes and goes based on your activity and commonly doing too much at one time.
- With a flare-up of knee arthritis pain, examine carefully your activity and what you may have done to trigger the flare-up to avoid in the future.
- If symptoms do not resolve in 7 days it is best to see a doctor, waiting weeks to get better allows too much muscle atrophy and disuse. It is better to allow your doctor to determine if these is knee swelling which may require stronger medication.
- With established arthritis and low-grade chronic symptoms these medications can still be used every other day or so along with ice and a knee brace to avoid stronger medications. Sometimes your doctor will recommend a knee steroid injection which lasts for up to three months an avoids using stronger oral medications that go thru your stomach and liver and have side effects.
- The use of glucosamine – chondroitin sulfate combination supplements is controversial although studies have shown they may provide some relief of knee pain in one-third of patients. These supplements are very safe, and their use is advantageous to avoid the side effects of stronger medications. The rule is to select a brand name that is recognized as studies show that these medications are not controlled by the FDA and may vary greatly in concentrations and what is actually present.
- One brand name that is recommended is COSAMIN DS (NUTRAMAX LABORATORIES) that is produced in the USA. One suggestion is to take the supplement for 4 weeks and determine if pain symptoms and joint stiffness improves. Another approach is to stop taking the medication after 4 weeks and see if there is a change in your symptoms. Often times these medications will help arthritis in other parts of your body such as hand arthritis so be aware other joints may benefit. It is appropriate to also take other over the counter medications as listed above as they do not have a cross reaction with these supplements.
- There are oral supplements such as Turmeric, and other herbs that patients will frequently ask a doctor if they are beneficial. I am very reluctant to recommend these other forms of supplements as medical science has not arrived at a precise opinion on their safety and use with other medications a patient may be taking. Also, with herb products, there may be contaminants or other potent chemicals as the quality of the product is not tested. Be careful of any herb or medication that you do know precisely the positive or negative effects.
- Following the above rules, I have had patients go many years, living an active life and avoiding side effects of stronger medications. Remember the use of cautious rehabilitation exercises and weight control is absolutely essential for success.
- Remember when knee arthritis flares up, your activity and the calories you burn will decrease therefore as already mentioned, it is important you stay as active as possible to effectively burn off calories. You may need serious modifications in your food intake and type of food you eat. Taking you weight weekly is recommended.
USE OF ORAL ANTIINFLAMMATORY PRESCRIPTION MEDICATIONS
- These medications are referred to as non-steroidal anti-inflammatory medications, NSAIDS and are used to block certain enzymes (COX enzymes) which are used by the body to produce prostaglandins that are chemicals that occur with knee arthritis that produce swelling and pain. Use these medications only with a doctor’s advice and try to use them for just one to two weeks at a time. Pay close attention to how these medications help you and if they are decreasing your pain and swelling symptoms.
- With knee arthritis it is common for pain to occur in getting out of a chair or going up and down stairs as you will place up to 6-8 times your body weight in doing these activities and medications frequently do not affect these symptoms. Rather the purpose of these medications is to make you comfortable for your normal activities of daily living. So, monitor how your feel overall in carrying out your daily activities. As knee arthritis flares up you may have to take these medicates for a few weeks, and then you may be able to stop taking them.
- Report to your doctor any medical problems before taking these medications. Patients with heart disease, elevated blood pressure or GI symptoms may be advised NOT to take these medications. Also, there are a number of different types of these medications and one type may not work, so report to your doctor if you are receiving a benefit.
- As the arthritis in the knee advances it may be necessary to take these medications more frequently and your doctor may require you to have blood tests for liver function on a routine basis. If you have stomach problems let you doctor know as there are types of NSAIDS referred to as COX 2 medications (Celebrex) that are gentler on your stomach as they do not affect the COX 1 enzyme that is beneficial for body gastrointestinal functions.
- Use your pharmacy to check the other medications you are taking to make sure there are no cross reactions. If you are on blood thinners or anticoagulation medications of any type these medications SHOULD be avoided. Be sure to obtain your doctors approval.
USE OF CREAMS APPLIED TO THE SKIN OVER THE KNEE JOINT
- There are a number of creams and advertisements of products to apply to the skin over the knee joint and true scientific studies are lacking as to their benefit. Some of the creams contain aspirin (salicylic acid) so be careful that you are not taking other medications that may conflict with aspirin products. Some of the creams contain a local anesthetic that would produce numbness of the skin but would not penetrate deep enough to decrease knee pain. I tell my patients if they wish to try these medications to do so in a conservative manner and to really check if they are beneficial.
- There are specific medical creams obtained by prescription that may provide a benefit to certain patients and I will frequently try these local creams over prescribing an oral medication. The most common cream is a Voltaren that is applied 2-3 times a day and may have a beneficial effect. Be careful with excessive application as some portion of the anti-inflammatory medication is absorbed and goes into your blood stream.
- There is a specific medical cream for patients who have a burning skin sensation or feeling or pins and needles or feeling of hypersensitivity. This means there is an increased stimulation of the local nervous system about the knee joint and there are specific creams and oral medications to decrease the nervous system response to the knee arthritis. Be aware of any burning or local aching as these are common symptoms of a nervous system disorder referred to as a Complex Regional Pain Syndrome (CRPS). Besides the burning sensation about the knee there is increased pain and sensitivity to touch of the skin about the knee. and there may be a major aching in the knee joint particularly at night. These symptoms mean the nervous system is acting in an accelerated manner to the knee arthritis and added treatment is necessary at an early stage. Do not put off receiving treatment for this nervous system problem as these symptoms may become PERMANENT if not treated early.
STEROID INJECTIONS FOR KNEE ARTHRITIS
- The steroid injection is commonly recommended for knee arthritis as the medication is placed directly into the knee joint, will frequently last for three months or longer and reduces knee pain, swelling and inflammation. The injection allows the patient to avoid taking strong oral medications. If there is knee joint swelling (joint effusion and fluid in the joint) this is a sign that the joint synovial lining is reddened and inflamed, and a steroid knee injection is beneficial.
- The steroid injection takes only a few seconds and is not like a steroid injection in the foot or hand that may be painful. Over 95% of patients experience only a mild discomfort, although on occasion there may be a sharp pain that lasts for 3-5 seconds as with any injection.
- The success rate of a steroid injection is in 80-90% of patients who will have decreased pain and have a benefit. The problem is that some patients will receive 3 months benefit or longer and other patients receive only a week or two. I only recommend a repeat injection after 3 months if this really helped the patient. There is a maximum of 3 and perhaps 4 injections a year, however this is still a “band-aid” and I will not repeat the injections year after year. Chronic recurring knee pain and dysfunction may indicate the need to move onto more definitive surgical solutions.
- The risks of a knee injection are very rare. The incidence of infection is less than 1 in 4000 injections as long as proper skin antiseptics are used. Rarely a patient will say that the injection produced increased knee pain, or a feeling of general body aches, or in women an increased menstrual blood flow, which represents rare signs that the steroid medication has produced a side effect and fortunately these symptoms will disappear in 24-28 hours in my experience. Even so they are reasons for not giving the steroid medication again.
- There is a rule that no surgery on the joint can be perfumed within 3 months of a joint injection to decrease any chance or risk of an infection with surgery.
USE OF HYALURONIC GEL INECTIONS FOR KNEE ARTHRITIS
- There are many different manufacturers and forms of the gel injection which vary from a single injection, to three injections to five injections. An insurance company will inform the patient on the type of gel shot approved based on agreements between the manufacturer and the insurance company.
- Be sure and inform your doctor if you are allergic to eggs or chicken products as some of the products represent a chicken derived and processed product. There are artificial forms of the Gel that avoid this issue.
- Most clinical studies will show a benefit of the Gel in 70% of patients in decreasing but not entirely eliminating pain symptoms. The injection can be repeated if necessary at 6-month intervals.
- In the past 5 years there were a few clinical studies that showed no major benefit of the Gel knee injection and this led some insurance companies to deny coverage. This has been an unfortunate situation as I have had the opposite experience of the Gel injections helping a majority of my patients.
- As the knee arthritis progresses to a bone-on-bone advanced condition these injections may not provide a benefit and the most benefit occurs before advanced arthritis.
- The risks of the injection are very rare and mainly the very rare occurrence of an infection that may occur anytime a body part is entered with a needle. On rare occurrence there may occur an allergic reaction to the Gel shot which requires immediate treatment with Benadryl or oral steroids.
PLATLET RICH PLASMA (PRP) INJECTION FOR KNEE ARTHRITIS
- There are many different manufacturers for this treatment and there is controversy over the best type of PRP injection and the frequency of the injections. These injections are not covered by insurance. There is a major need for good clinical studies on PRP treatments. In the platelet portion of the blood there are a number of potentially advantageous factors that decrease joint inflammation and block the abnormal chemicals produced with knee arthritis. The PRP factors that are injected act in a major way to decrease the inflammation and block the action of harmful enzymes produced in the knee joint with knee arthritis.
- Some clinical studies show an added benefit of PRP injections in patients with knee arthritis that have failed other injections listed above. Unfortunately, other studies have shown no benefit to patients. I advise patients that these injections are safe, and the process involves taking the patient’s own blood, spinning down the blood to obtain the platelet portion which is then injected into the knee joint similar to the other injections discussed above.
- There are major studies in progress at clinical research facilities in the USA that will help resolve some of the unknow issues surrounding PRP injections. Therefore, patients may choose a PRP injection paying for it out of their own resources, hoping for a benefit.
- Other times, because insurance does not cover the fee, the patient will adopt a wait and see approach. The goal is to educate the patient on the plus and minus aspects of PRP injections and not to expect any overwhelming effects of this treatment. Still from a positive note, the PRP injection may in certain patients provide a benefit over months in decreasing symptoms and delaying surgery. It is best with these newer treatments to have a complete transparency with the patient for informed consent and not to accept the over promotional and excess marketing in the media that often have overstated the benefits.
UMBILICAL CORD BLOOD AND PLACENTA KNEE INJECTIONS FOR ARTHRITIS
- There are a number of manufactures and these products are being promoted with still little in the way of scientific evidence to substantiate their effects and efficacy. These injections are not covered by insurance. Recently the FDA has started legal actions against some manufactures where there is a question of the sterility and increased risk of infections. There have been major reports of infections in New York and in California after use of these products. This is not to deny that there may be manufactures who are following FDA approved methods.
- A major problem I observe in internet promotion of these products is the use of the work “reparative” or “restorative” suggesting that these injections may repair damaged joint tissues. This is false advertising and has never been proven that the arthritis can be reversed or healed. In fact, the FDA has taken legal actions when this type of misrepresentation occurs in marketing and advertising. The entire aspect of promotion and marketing of these products has produced a profound misunderstanding of their efficacy. Many physicians acknowledge that the FDA has erred in not taking a more robust response to ensure accurate statements by manufacturers and marketing to patients.
- THE FDA has issued requirements for Umbilical Cord products to present in 2020 the scientific evidence of clinical efficacy and results which will result in a number of companies unable to achieve FDA approval. Because of these controversial issues and the lack of scientific data and proven clinical studies our Knee Institute does NOT offer these products to our patients. If you are considering this type of injection, be advised to ask questions as to who the manufacturer is and the steps taken to prove a sterile product that will not have a risk of infection or other deleterious side effect.
BONE MARROW INJECTIONS (BMAC) FOR KNEE ARTHRITIS
- The use of BMAC injections for knee arthritis is one of the first biologic treatments and has been performed in Europe for many years. There are reported clinical studies which show in patients a beneficial response in decreasing pain and improving function. The BMAC is removed from the pelvic bone (iliac crest) which does require local anesthetic and pain medication. The BMAC is injected into the knee joint, or in certain instances directly into the thigh bone (femur) or leg bone (tibia) at the knee joint. The site of injection is often selected from an MRI which shows edema and fluid in the bone suggesting this area is painful.
- Due to the above needs for a facility and trained personnel, and fluoroscopy the costs associated with the procedure are much higher. Some insurance programs will cover the injections directly into the bone, but not into the joint.
- There are still limited clinical outcome studies for this procedure and it is not possible to predict what patients will benefit and for how long the treatment will last. There are centers in the USA who are performing clinical studies and a note of caution is appropriate for patients to wait and see the results of further clinical studies. In an ongoing study of this procedure at our Knee Institute the results do show a benefit in 70% of the patients for 6 months, and sometimes longer however the pain is not entirely relieved and there are still symptoms that limit activities. Often times the BMAC injection is used in patients to buy time and allow for weight loss and optimization of medical issues before a knee replacement is performed.
FAT CELL INJECTIONS FOR KNEE ARTHRITS
- This is a new type of treatment in which fat cells are taken from the abdomen and then injected into the knee joint to decrease inflammation and symptoms.
- This treatment has been marketed to have the highest stem cell count of other products. Again it is important to note that no study has ever shown that there are active stem cells that will reverse the arthritis process or regenerate and reform the damaged areas.
- There are clinical research trials underway in the USA, and our Knee Institute made the decision not to offer this product to our patients until scientifically proven to have a benefit.
Final Comments on stem cell injections (PRP, BMAC Fat cells) What you need to know:
- The use of the term “Stem Cell Injections” and “Regenerative Therapy” is very misleading and not truthful. The number of stem cells is very few in all these products and stem cells do not function to repair tissue. The stem cells do not “differentiate” into another cell to renew or repair cartilage or ligament.
- The benefit of both PRP and BMAC injections are that a number of growth factors and other factors are in the injection and work to reduce inflammation, and block chemicals released into the knee joint due to joint damage.
- The injections promote a healthier joint environment and decreases pain, swelling and stiffness initially in many patients, but this is not permanent. There are no regenerative or repair actions that occur. The term “Regenerative Therapy” is incorrect and false advertising.