This a question that I often receive after evaluating a patient and informing them that they have arthritis in the knee. Sometimes they verbally ask the question. Often I just see the panic in their eyes. The good news is that there is very effect knee arthritis treatment without surgery.
I am quick to reassure them that just because they have arthritis, does not mean that they need surgery. In fact, if this is the first that they are hearing about their arthritis, there is a good chance that surgery is not in their immediate future, if ever.
What is arthritis?
So let’s first talk about arthritis. There are several types of arthritis. For this post, I am going to be talking about the most common type of arthritis which is osteoarthritis. Osteoarthritis or OA is caused by a breakdown of the articular cartilage in the joint. Articular cartilage is a smooth covering of the boney surfaces within the joint. It allows the bones to glide on one another without friction during movement. As the articular cartilage erodes, the bones will begin to become irritated and form bone spurs. As OA progresses, the joint itself will become deformed – usually becoming severely bow-legged or knock-kneed. It will tend to be unilateral (just one knee). However I have had patients that have had severe OA in both knees. These people tend to have secondary OA rather than primary.
Types of OA
There are two different types of OA
- Primary OA
- This is the breakdown of articular cartilage without any known reason. This type of arthritis is usually contributed to age, and wear and tear over time.
- Secondary OA
- In this type of OA, there is a known reason for the breakdown. Possible causes of the breakdown include
- Joint hypermobility – overly flexible or “double jointed”
- Congenital defects
- Family history
- Previous trauma to the joint
- Malpositioning of the joint – knock-kneed or bow-legged
- Obesity
- In this type of OA, there is a known reason for the breakdown. Possible causes of the breakdown include
Symptoms of OA
There some common symptoms of OA. These include:
- Stiff and swollen knee – OA can cause inflammation in the knee. Patients can have long periods of time when there knee doesn’t hurt but then it becomes inflamed by a certain movement or activity.
- Pain and stiffness after prolonged sitting or resting – This is really the cardinal sign of OA. The knee is really stiff first thing in the morning but does okay after warming up. It also stiffens up after sitting or resting too long.
- Increased pain with certain activities – These activities would be the cause of the flare-ups of arthritis pain. In my patient population, these activities often include playing tennis or pickle ball, walking for an extended time, prolonged standing, going up and down steps, and squatting. However this list is not exhaustive as there are endless ways to flare-up arthritis.
- Snap, crackle, and popping of the knee – This is crepitis. This is another telltale sign of arthritis. I have several patients whose knees I can hear bending from across the room.
Grades of arthritis
Not all OA is the same. There are grades that will differentiate the extent that it is affecting the joint.
- Grade 0: This a normal knee with healthy articular cartilage.
- Grade 1: This is a knee with some bone spurring but the person is not experiencing any pain.
- Grade 2: This is the stage when people begin to feel pain. The OA is still mild at this stage but bony growth or a spur is evident on x-ray.
- Grade 3: At this stage, people are feeling more pain during movement. There is also more joint stiffness in the morning and after prolonged sitting. The space between the joint surfaces is smaller and the articular cartilage is significantly damaged.
- Grade 4: This is the last and most severe grade. The articular cartilage is almost completely eroded and the joint space is greatly reduced. This is the bone on bone stage. There are generally high levels of pain with walking and moving the knee. This is when most people get knee replacement surgery.
The knee
The knee is the largest joint in the body and is also one of the joints that is most susceptible to arthritis. The knee is made up primarily by the tibiofemoral joint and patellofemoral joint. The tibiofemoral joint is what most of us think of as the knee. It is the joint made between the bottom of the femur (the thigh bone) and the top of the tibia (the shin bone). The patellofemoral joint is the joint made between the femur and the patella (the kneecap). Arthritis might be present in one or both of these joints.
Knee arthritis is very common and is something I treat in the clinic on a near daily basis. There are several reasons that knee OA is so prevalent. The knee is a weight bearing joint which means that it has to support the weight of the body. Any time a person is upright, there is stress through the knee. This includes walking, sitting, standing, running, jumping, and many other activities.
Risk factors for OA
Because the knee supports the weight of the body, any abnormal stresses on the knee can cause OA to develop over time. This includes a prior injury, such as a ligament tear at the knee, which can lead to OA from joint instability or abnormal walking. People who are born with knees that are overly bowed or knock-kneed will also be more likely to develop OA. Those who are overweight or obese are more at risk for OA because of the increased load put through the knee joint.
Knee surgery?
Unfortunately there is no way to cure OA. However, there are many ways to manage it and slow the progression. Physical therapy can play a big role in knee joint preservation and slowing the development of OA.
And just because you have OA, does not mean that you need surgery. Joint replacement surgeries are very common and very successful for many people. However those people probably had grade 4 OA going into surgery and were having severe pain and difficulty with mobility. Most of my patients with knee OA are not that severe. However I do have a few grade 4 OA patients who either do not want surgery or want to put it off as long as possible.
I currently have a patient with grade 4 OA in both of his knees. I have been seeing him for 5 years. He was 45 when I began seeing him and his knees were already at a grade 4. He has always had very bowed legs and liked to play sports which led to a lot of stress on his knees. He wanted to wait until he was older before he had his knees replaced. He is now 50 and preparing for his first knee replacement this fall. Physical therapy has allowed him to stay active, travel, work, and perform most of the activities of life with manageable pain. He still has pain if he does too much, but overall, he manages very well for the amount of deformity he has at his knee joints.
How can physical therapy help?
Physical therapy is the primary conservative treatment for knee OA. Physical therapy is immeasurably helpful in improving pain, inflammation, joint mobility, range of motion, strength, and flexibility. We can also help decrease stresses on the joint by improving walking quality, muscle activation, and joint mobility.
What can you do?
There are many things that you can do to help the health of your knee joint.
- Aerobic exercise – This is the type of exercise that gets your heart rate up. It is not only good for your heart but also your joints. Your joints need to move to stay healthy. However if you have knee OA and your only aerobic activity is walking, then you might want to start diversifying. To decrease the stress on your knee joint, consider biking and swimming. These are non-weight bearing forms of exercise which will decrease the stress on the joint. This is not to say that you cannot walk for exercise, especially if your OA is mild, but I would not make it the only or primary form of activity.
- ROM exercise – This type of exercise helps to improve the mobility of the knee joint. It will help improve your ability to bend and straighten the knee.
- Hip and knee strengthening – Having good strength in the knees and hips will help improve walking quality, knee alignment, and decrease the stress on the knee. Using resistance bands can add difficulty and improve strength.
- Weight management – Because the knee joint supports the weight of the body, it is important to try to maintain a healthy weight. Even a small amount of weight loss can make a big difference in knee pain.
- Shoe wear – Wearing good supportive shoes can also make a difference in knee pain and knee alignment. Flat feet can change knee alignment if they are not properly supported. Good soled shoes can also help with shock absorption when walking.
- Ice and heat – Heat can help get the knee moving in the morning or when it feels really stiff. Icing the knee with an ice pack can help decrease the inflammation caused by activity. Ice and heat for about 20 minutes at a time.
- Knee brace – An offloader brace is what is typically recommended for knee OA. It helps to decrease the stress on the knee. However, it tends to be very bulky and many of my patients do not like wearing it. I often recommend just getting a simple knee sleeve for the compression and the feeling of increased support.
- Find a good orthopedist and physical therapist – If you have knee arthritis, and it is starting to hurt, it is time to find a good orthopedist and physical therapist. An orthopedist who specializes in knees can be very beneficial in monitoring the arthritis progression and providing other medical interventions. A physical therapist is needed to help slow the progression of the arthritis and, also, to decrease the pain and inflammation during a flare-up. You will most likely see both of these medical professionals multiple times as the knee pain waxes and wanes.
In review
- Osteoarthritis is a breakdown of the articular cartilage of the bones that make up the joint. This causes bone spurs and decrease space in the joint.
- Stiffness and pain when getting up in the morning and after rest is the hallmark symptom of osteoarthritis of the knee.
- Not all arthritis is the same – There are grades of osteoarthritis.
- Find a good physical therapist. Physical therapy is essential in helping slow the progression of the arthritis and decrease the current pain, stiffness, and swelling.
- Find an orthopedist who specializes in knees to help monitor the arthritis progression
- Things you can do include:
- Aerobic, strengthening, and range of motion exercises
- Managing your weight – even a small amount of weight can translate into a significant decrease in knee pain
- Wear supportive shoes
- Use ice and heat to help inflammation and stiffness
- Use a brace to help decrease pain, swelling, and add support to the knee
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Knee_Osteoarthritis
https://www.ncbi.nlm.nih.gov/books/NBK507884/
https://www.choosept.com/guide/physical-therapy-guide-osteoarthritis-of-knee