How to treat knee arthritis without surgery
At the Noyes Knee Institute, knee arthritis is normally treated first with all conservative measures that include lifestyle changes (weight control or loss, avoidance of activities that can aggravate the knee), medications, injections, physical therapy, and supplements. We try to use the least amount of medication possible. In many cases of mild to moderate arthritis, occasional use of over-the-counter pain and anti-inflammatory medications, along with modification of activities and weight loss, is often effective in controlling symptoms.
The proper precautions regarding the use of all medications should be discussed with your physician. There are risks with taking nonsterodial anti-inflammatory medications (NSAIDs), including those related to gastrointestinal (nausea, bleeding, ulcers) and cardiovascular (stroke, heart attack) systems. These risks only occur in a small amount of patients, but it is still important that you are informed.
Treating Arthritis Without Surgery
Everything You Need to Know to Make the Right Treatment Decision
Everything You Need to Know to Restore Knee Function and Return to Activity
Medications: Oral Over-the-Counter
These medications can be highly effective in the initial stages of knee arthritis. Use the common medicines you would use for a headache (Tylenol, Advil, or Aleve) for knee pain. Advil and Aleve are in a class of nonsteroidal medications referred to as NSAIDS and are used in smaller doses to decrease pain and swelling.
Also use ice, activity modification, and rest to allow your knee “headache” to resolve. Remember, knee arthritis pain comes and goes based on your activity. It may flare-up if you do too much at one time. When this occurs, examine carefully your activity and what you may have done to trigger the flare-up to avoid other occurrences in the future.
If your symptoms do not resolve in 7 days, it is best to see a doctor because waiting weeks to get better allows muscles to atrophy (get weak). Your doctor can determine if there is knee swelling which requires 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 that lasts for up to 3 months and avoid using stronger oral medications that go through your stomach and liver and have side effects.
Following the above rules, I have seen many patients do well for several years, living an active lifestyle and avoiding side effects of stronger medications. Remember, the use of cautious rehabilitation exercises and weight control is absolutely essential for success.
When knee arthritis flares up, your activity level and the calories you burn will decrease. Therefore, 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. Limit your sugar intake in the amount of carbohydrates consumed, increase proteins in your diet, and decrease the size of food portions. Check your weight weekly.
Medications: Prescription Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Non-steroidal anti-inflammatory drugs (NSAIDS) are used to block certain enzymes (COX enzymes) that are used by the body to produce prostaglandins. These are chemicals that occur with knee arthritis that produce swelling and pain. Use NSAIDS only with a doctor’s advice and try to use them for just 1-2 weeks at a time. Pay close attention to how these medications help you and if they decrease your pain and swelling symptoms.
With knee arthritis, it is common for pain to occur when getting out of a chair or going up and downstairs because you place up to 6-8 times your body weight on your knee when doing these activities. The primary purpose of NSAIDS is to make you comfortable for your normal activities of daily living. So, monitor how you feel overall in carrying out your daily activities. As knee arthritis flares up, you may have to take these medications for a few weeks and then you may be able to stop taking them.
Report to your doctor any medical problems before taking NSAIDS. Patients with heart disease or elevated blood pressure may be advised to NOT take these medications. Also, there are different types of NSAIDS, so report to your doctor if you are not receiving a benefit and you may want to try a different medication.
As your knee arthritis advances, it may be necessary to take these medications more frequently and your doctor may require you to have blood tests for kidney and liver function on a routine basis. Let your doctor know if you have stomach problems. There are certain 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.
Your pharmacist will check any other medications you are taking to make sure there are no cross-reactions. NSAIDS should be avoided if you are on blood thinners or anticoagulation medications of any type.
Medications: Oral Supplements
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. We recommend using a recognized brand name because these medications are not controlled by the FDA and may vary greatly in concentrations and other ingredients present.
One brand we recommend is Cosamin that is produced in the USA. Take the supplement for 4 weeks and determine if pain and joint stiffness improve. You can then stop taking the medication after 4 weeks and see if there is a change in your symptoms. Often, these medications will help arthritis in other parts of your body such as hand arthritis. It is appropriate to also take other over the counter medications because they do not have a cross-reaction with these supplements.
There are other oral supplements such as Turmeric and herbs that patients will frequently ask a doctor if they are beneficial. I am very reluctant to recommend these other forms of supplements because 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 because the quality of the product is not tested. Be careful of taking any herb or medication that you do know precisely the positive or negative effects.
There are a number of creams available to apply to the skin over the knee joint and true scientific studies are lacking as to their benefit. Some of these 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 see if they believe they are beneficial.
There are prescription medical creams that may provide a benefit to certain patients and we frequently try these local creams over prescribing an oral medication. The most common is Voltaren that is applied 2-3 times a day and may have a beneficial effect. Be careful with excessive application because some portion of the anti-inflammatory medication is absorbed and goes into your bloodstream.
There is a medical cream for patients who have a burning skin sensation or feeling of 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. Besides the burning sensation about the knee, there is increased pain and sensitivity to the touch of the skin about the knee. 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.
Knee Injections: Corticosteroid
A steroid injection is commonly recommended for knee arthritis because the medication is placed directly into the knee joint, will frequently last for 3 months, reduces knee pain, swelling and inflammation, and allows the patient to avoid taking oral medications. If there is knee joint swelling (fluid in the joint), this is a sign that the joint synovial lining is inflamed and an injection is indicated. Corticosteroids mimic the effects of a substance known as cortisol that is produced naturally by the adrenal glands. This substance helps decrease levels of prostaglandins and reduces the interaction between certain types of white blood cells involved in the immune response that may cause inflammation.
The knee injection only takes a few seconds and you should understand that this is not like a steroid injection you may have had in other parts of your body, such as the foot or hand that may be painful. Over 95% of patients experience only mild discomfort, although on occasion there may be a sharp pain that lasts for 3-5 seconds as with any injection.
We have found that 80-90% of patients have decreased pain following a steroid injection. The problem is that while some patients receive 3 months of benefit, others report only a week or two of pain relief. We 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 we will not repeat the injections year after year because the chronic recurring pain and dysfunction may indicate the need to move onto more definitive surgical solutions.
The risks of a complication from 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. In women, an increased menstrual blood flow rarely occurs, which represents signs that the steroid medication produced a side effect. Fortunately, these symptoms disappear in 24-28 hours in our experience. However, they are reasons for not giving the steroid medication again.
There is a rule that no surgery on the joint can be performed within 3 months of a joint steroid injection to decrease the risk of infection with surgery.
Knee Injections: Hyaluronic Acid, or Viscosupplementation (Gel)
Hyaluronic acid is a natural substance in the knee joint that helps coat cartilage and acts as a lubricant and shock absorber that allows your knee to move freely without pain. Patients with moderate or severe arthritis typically do not have enough hyaluronic acid and this is part of the reason they experience pain and swelling. The purpose of viscosupplementation or gel injections is to replace or supplement your own hyaluronic acid. The most common medications used are sodium hyaluronate (Hyalgan, Supartz), hylan G-F 20 (Synvisc, Synvisc One), cross-linked hyaluronate (Gel-One), and high molecular weight hyaluronan for patients with sensitivities or allergies to birds or chickens, eggs, and feathers (Durolane, Monovisc, Orthovisc). The FDA in the U.S. approved of this treatment for knee arthritis in 1997.
Hyaluronic acid or gel treatments vary from 1 to 3 to 5 injections. Some insurance companies will approve these injections based only on agreements between the manufacturer and the insurance company. Be sure and inform your doctor if you are allergic to eggs or chicken products because some of the products represent a chicken-derived and processed product. There are artificial forms of this medication available that avoid this issue.
Most clinical studies report pain relief from viscosupplementation lasting approximately 3 to 6 months. A recent meta-analysis found that single-injection products were as effective as multiple injection products for knee arthritis pain relief at 3 and 6 months. In 2016, the American Medical Society for Sports Medicine published a position statement regarding the treatment of knee arthritis with hyaluronic acid versus corticosteroid injection. The society recommended hyaluronic acid in patients over the age of 60 years based on the results of a meta-analysis of 11 randomized controlled trials.
Side effects of these injections are usually mild and include redness, swelling, and skin irritation at the injection site. On rare occurrences, there may be an allergic reaction to the Gel shot which requires immediate treatment with Benadryl or oral steroids.
Overall, gel injections are well-tolerated and considered an effective option for patients with mild to moderate arthritis in whom other conservative medications have failed. Patients who have a large amount of inflammation or synovitis, or in whom advanced bone-on-bone arthritis exists, are not expected to receive as much pain relief from this therapeutic option.
Knee Injections: Platelet Rich Plasma (PRP)
Injection of PRP is another treatment option for knee arthritis. There are many different manufacturers and controversy exists regarding the best type of PRP injection, along with the frequency and number of injections. The platelet portion of the blood specimen contains a number of potentially advantageous factors that decrease joint inflammation and block the abnormal chemicals produced with knee arthritis.
Many studies have shown PRP injections have relieved knee pain for 6 to 12 months. However, there are conflicts in the medical literature as to whether PRP is better or the same as hyaluronic acid injection therapy in providing pain relief and an increase in knee function. To date, 13 randomized studies have compared these treatment methods and the results showed inconsistent findings at 3, 6, and 12 months. The main problem is that the studies used different injection protocols, PRP preparation methods, different hyaluronic acid medications.
We advise patients that PRP injections are safe. The process involves taking the patient’s own blood, spinning it down to obtain the platelet portion, and then injecting that into the knee joint similar to the other injections discussed above. There is a low risk of complications after PRP injections, which may include local infection and pain at the site of the injection.
There are major studies in progress at clinical research facilities in the USA that will help resolve some of the unknown 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. It is best with newer treatments to have complete understanding with the patient for informed consent and not accept the over-promotion and excess marketing in the media that often have overstated the benefits.
Knee Injections: Stem Cell Caution
From "Be Committed to Stem Cell Therapy" by Anthony Romeo, M.D., Editor, Orthopedics Today, June 2019
The field of stem cell implantation is complicated and may be confusing to patients. The following statements are from an article published in Orthopedics in June of 2019:
"Unfortunately, the allure of stem cell treatment in an industry-favorable regulatory environment has spawned a multibillion-dollar sector of health care that threatens to erode public trust in our stewardship of musculoskeletal care. The number of properly designed, randomized, controlled trials investigating outcomes of stem cell treatment for orthopedic conditions that include efforts to minimize the placebo effect and other confounding variables is almost non-existent.
The Lancet Commission on Stem Cells and Regenerative Medicine concluded: “The combination of poor quality science, unclear funding models, unrealistic hopes, and unscrupulous private clinics threatens regenerative medicine’s social license to operate.”
Stem cell therapy holds tremendous promise as part of the “ingredients” for regenerative therapies to treat musculoskeletal conditions. We must be committed to the science and investigation of stem cell therapies, understand the impact of marketing unproven and potentially harmful treatments and have an intelligent and open dialogue with patients."
Knee Injections: Stem Cells From Bone Marrow Aspiration and Concentration (BMAC)
In the U.S., the only approved stem cell injections use adult cells taken from the patient's own bone marrow or fat. The use of BMAC injections for knee arthritis is one of the oldest types of biologic treatments and has been performed in Europe for many years.
The BMAC is removed from the pelvic bone (iliac crest) which may be painful and require pain medication. Most centers in the USA have specific facilitates for this procedure to ensure a sterile environment and decrease the risk of infection. The cells are placed into a centrifuge and prepared for injection. 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 exact site of the injection is often taken from MRI which shows edema and fluid in the bone.
This is an expensive procedure because it requires an MRI, sedation under anesthesia at a surgery center, fluoroscopy, pain medication, and possible arthroscopy. Most insurance companies do not cover the cost of this treatment.
Studies show that approximately 70% of patients with moderate to severe arthritis may experience pain relief for 6 to 12 months. However, it is important to note that to date, the quality of published studies has been low with few control (comparison) groups and it is not possible to predict which patients will benefit. There are centers in the USA that are conducting more rigorous studies and some patients may wish to wait for the results of these investigations before proceeding with this treatment option.
Knee Injections: Stem Cells From Umbilical Cord Blood and Placenta
Stem cells may also be obtained from donor tissues such as amniotic fluid and the umbilical cord. However, these are not approved for the treatment of osteoarthritis in the U.S. by the FDA. There are many manufacturers and these products are being promoted with little in the way of scientific evidence to substantiate their effects and efficacy. Recently, the FDA began legal action against some companies where there is a question of the sterility and risk of infections. There have been major reports of infections in New York and California after use of these products.
A strong warning has been issued (in 2019) regarding unproven stem cell treatments and aggressive and false advertising of claimed effects of this therapy. These statements typically claim that stem cell therapy is a "curative treatment" and that "you can literally grow new joint tissue". 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.
There are documented incidences of serious complications from these treatments, including the formation of cancer tumors, blindness, and severe infections. Be especially careful of clinics operating outside the U.S. in regard to misleading statements. Stem cell therapy costs range from $3,000 to $15,000 U.S. dollars and the Federal Trade Commission has begun investigating U.S. clinics and imposing multimillion-dollar fines for violation of truth in advertising laws.
The FDA has issued policy statements and requirements for umbilical cord products to present in 2020 scientific evidence of clinical efficacy and results. We expect this will result in a number of companies that will not 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 as a patient 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 effects.