Osteoarthritis of the Knee
Welcome to this guide regarding osteoarthritis (OA, or degenerative joint disease) of the knee.
This Decision Guide is designed for persons who have learned that they have OA and would like to find out more about this condition and what they might be able to do about it.
Please keep in mind that this information cannot replace a face-to-face evaluation with your own health care provider. It is meant to provide helpful information while you are awaiting further evaluation, or to supplement what you may have already learned after evaluation with your doctors.
Would you like to start with some general information about OA? Or would you prefer to get information more specific to your own situation?
Okay. The information will be presented in the following categories:
Causes -- who gets OA and why
Treatments -- therapies that may be helpful
Course/prognosis -- what to expect
Future directions -- what may lie ahead for the treatment of OA.
Let's start with the causes of OA.
Osteoarthritis is particularly common among older people, but it is not an inevitable part of aging and age does not cause OA. In other words, it is not "normal" for an elderly person to have joint pain. Anyone who has bothersome joint pain, elderly or not, should be thoroughly evaluated by a health care provider. There are many causes of joint pain and many types of arthritis; appropriate treatments vary accordingly. It is never a good idea to assume that joint pain is "just due to aging."
There probably is no single cause of osteoarthritis, and, for most people, no cause can be identified. Factors other than age seem to contribute to osteoarthritis. People who sustain injuries or small repetitive injuries as a consequence of repeated movements on the job or those with sports-related injuries may be at increased risk of developing osteoarthritis; this may occur at any age. There may be a genetic component involved, especially in the development of osteoarthritis in the hands. Obesity seems to be a factor in osteoarthritis of the knees. Other recognized risk factors for osteoarthritis include
repeated episodes of bleeding into the joint, as may occur in hemophilia or related bleeding disorders
repeated episodes of gout or pseudogout in which episodes of inflammation follow the deposition of uric acid or calcium crystals into the joint
avascular necrosis (AVN), a condition in which the blood supply to the bone near the joint is interrupted, leading to bone death and eventually joint damage. The hip is the most commonly affected joint, but the knee can also develop AVN
chronic inflammation caused by previous rheumatic illness, such as rheumatoid arthritis
metabolic disorders, such as hemochromatosis, in which a genetic abnormality leads to too much iron in the joints and other parts of the body
previous joint infection.
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The first step is to have an evaluation with your health care provider so that the diagnosis of osteoarthritis can be established. For the most part, health care providers diagnose osteoarthritis on the basis of symptoms that are evident during an office visit and on physical examination. Once the diagnosis is clear, a number of treatments can be considered, depending on the severity of symptoms, other medical problems and your preferences.
Mild pain relievers (oral analgesics). The stiffness and pain of osteoarthritis are often relieved by an over-the-counter pain reliever, such as acetaminophen (Tylenol). Because acetaminophen is considered safe and potentially effective, most health care providers suggest that treatment begin with this drug.
Anti-inflammatory drugs and other pain relievers. If an over-the-counter pain reliever fails to relieve your symptoms, your health care provider may suggest a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil, Motrin and others) or naproxen (Aleve, Naprosyn and others). You should only use NSAIDs, especially if you use them regularly, under the supervision of your health care provider. Do not combine them with other drugs without talking with your health care provider first. Stomach problems, including ulcers, are the most common side effects. Newer NSAIDs, such as celecoxib, may be safer for people who are at risk of stomach ulcers, including those who have had ulcers in the past.
Stronger pain medications, such as tramadol or even narcotics such as codeine, are sometimes suggested if over-the-counter pain relievers and NSAIDs fail to relieve osteoarthritic symptoms.
Topical pain relievers (topical analgesics). Topical pain relievers can be applied to the skin over the affected joint as an alternative to, or in addition to, oral pain relievers. Topical pain relievers include methyl salicylate and capsaicin cream. Capsaicin, a substance obtained from hot chilies, may cause mild skin irritation or a burning sensation when applied to the skin.
Corticosteroid injections. When osteoarthritis is accompanied by inflammation, as indicated by warmth and an accumulation of fluid in the joint, your health care provider may recommend that some joint fluid be removed. After fluid is removed, a corticosteroid drug can be injected into the joint. This procedure usually has short-term effects and is used almost exclusively for acute (sudden) and severe symptoms, especially for osteoarthritis of the knee. It is important to recognize that overuse of this procedure has risks, including an increased risk of infection, thinning of the skin and tendon rupture. Because of these potential dangers, your health care provider will recommend this treatment infrequently -- and only when absolutely necessary.
Dietary supplements. The dietary supplements glucosamine sulfate and chondroitin sulfate are over-the-counter agents currently under investigation for the treatment of osteoarthritis. Recent research suggests that these agents may safely provide some benefit for people with osteoarthritis in the knee. The results of more definitive, ongoing studies will show whether these agents act as mild pain relievers or whether they also help heal the damaged joint.
Hyaluronate. Hyaluronate is a newer treatment for osteoarthritis that may provide mild relief of symptoms in some people. This chemical ordinarily provides the joint with lubrication and nutrition. Synthesized forms can be injected directly into an osteoarthritic knee once a week for three to five weeks; it is not clear whether repeated courses are effective. Some health care providers do not believe the modest benefits are worth the risk and discomfort of the injections.
Joint reconstruction or replacement. Health care providers recommend orthopedic surgery in cases of severe osteoarthritis in which there has been significant deterioration of the joint. Surgery can be used to correct joint deformity, to reconstruct a diseased joint or to completely replace a diseased joint with a prosthetic device. This surgery is most often recommended for osteoarthritis of the hip or knee, because severe disease of these joints can impede movement. Joint replacement is definitive treatment for severe osteoarthritis, and hip replacement and knee replacement are among the most common surgeries performed in the United States. A replaced joint will last an average of ten to 15 years (or even longer, because these estimates are based on operations performed at least ten years ago).
Arthroscopy. Arthroscopy is another surgical treatment option for osteoarthritis. But in contrast to joint reconstruction or replacement, arthroscopy is considered minor surgery in that it generally does not require an overnight stay in the hospital. An arthroscope is an instrument with a tiny light, a camera and a variety of surgical attachments. The instrument is inserted into the joint to perform minor surgery using the attachments. Ragged joint edges, debris and loose material can be visualized and either smoothed over or removed. Depending on the condition of the joint, this can result in mild to moderate improvement that may last several months or perhaps a few years; however, for someone with severe osteoarthritis, this approach is unlikely to offer much benefit.
Cartilage transplant. Cartilage transplant is a method to replace damaged cartilage with healthy cartilage transplanted from elsewhere in the body or from a person who has died and donated their organs. Cartilage cells may be removed from a joint or some other area and grown outside the body to form a "patch." The patch is then inserted in an area of damaged or missing cartilage with an arthroscope. So far, these approaches have been used primarily in young people with sports-related injuries limited to the knee. But many experts believe that the time is soon coming when cartilage transplant will become a more common treatment for osteoarthritis.
Treatments Other Than Drugs or Surgery
Education. Top on the list of nondrug and nonsurgical approaches to osteoarthritis is patient education. You can learn about your disease and various ways to manage it from your health care provider. Or search the library or reliable sites on the Internet. In addition, there are arthritis self-help courses available in many communities, hospitals and clinics.
Weight loss. Obesity is a known risk factor for osteoarthritis. Weight loss may help decrease the odds of developing symptoms of osteoarthritis. Researchers are investigating whether weight loss slows the progression of the disease and whether it can help to relieve symptoms. For these reasons, many health care providers recommend that overweight patients with osteoarthritis participate in weight-management programs that include dietary counseling and exercise. This may be particularly important for patients who may need surgery, because significant obesity may increase the risk of complications.
Rehabilitation services. Several forms of rehabilitation services are available to people with osteoarthritis. These include physical therapy, occupational therapy and podiatry. A rehabilitation service may help you relieve your pain and improve your ability to function with the use of a cane, a splint, specific exercises, joint protection maneuvers, education, shock-absorbing shoes or orthotics (shoe inserts).
Exercise. Exercise can be helpful for people with some forms of osteoarthritis, such as arthritis of the knee. For example, walking programs and water aerobics may help improve functioning and relieve pain.
Application of heat or cold. A heating pad or ice pack sometimes provides comfort and relieves pain. If you use these methods, be sure to protect your skin from exposure to extreme temperatures.
Complementary and alternative medicine. There are several other safe and potentially effective ways to treat osteoarthritis without drugs or surgery that are generally considered "alternative" or "complementary" to more traditional options. These include:
Chiropractic care. This form of therapy attempts to decrease pain and restore normal function by manipulating the structures of the body, primarily the spinal column. Manipulation of the neck, however, should be performed with caution if at all because nerve or spinal cord injury may rarely complicate such therapy.
Acupuncture. Fine needles are inserted into the skin at certain points of the body in an attempt to relieve pain and promote well-being.
Massage. The muscles of the body are kneaded in an effort to relieve pain.
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