Osteoarthritis, also known as degenerative joint disease, is the most common form of arthritis (inflammation and irritation of the joints), affecting millions of people worldwide. Although osteoarthritis can affect any joint, knee osteoarthritis and degeneration of the joints in the hands, hips, and spine are the most common. This article focuses on knee osteoarthritis or degeneration.
The knee joint is the largest synovial joint in the body, formed by the meeting of the femur (thigh bone), tibia (shin bone), and patella (kneecap). At the ends of these bones, there is a strong, smooth structure called hyaline cartilage, which allows these structures to move smoothly over each other. Two additional cartilages, the medial and lateral menisci, are located between the femur and tibia. Several ligaments (such as the anterior cruciate ligament and posterior cruciate ligament) connect these bones and prevent improper movements. These structures are surrounded by a tough tissue called the joint capsule.
What is Knee Osteoarthritis or Degeneration?
Any factor that causes irritation and degeneration of the hyaline cartilage at the ends of the bones can lead to osteoarthritis in the joint. As the disease progresses, the cartilage completely wears away, and the bones come into direct contact with each other. Bone spurs may also form at the edges of the bones, which can sometimes be felt. In knee degeneration, the joint space decreases, and the bones move closer together, contrary to the misconception of many patients who believe that the space between their bones has increased.
1. Age: The likelihood of developing osteoarthritis increases with age, with 80% of people over 55 showing some degree of osteoarthritis.
2. Gender: Women are more likely to develop osteoarthritis, although the exact reason is unclear.
3. Overweight and Obesity: Excess weight puts additional pressure on weight-bearing joints (hips and knees), increasing the risk of osteoarthritis. Additionally, fatty tissues produce proteins that may cause inflammation in and around the joint.
4. Occupation: Jobs that require frequent kneeling, standing for long periods without adequate movement, or repeated use of stairs can increase the risk of knee degeneration.
5. Genetics: Some individuals have a genetic predisposition to osteoarthritis.
6. Joint Injuries: Injuries to the joint during sports or accidents, such as tears in the cruciate ligaments or menisci, can increase the risk of knee degeneration. These injuries may have occurred in the past and been forgotten.
7. Biomechanical Issues: Certain biomechanical issues, such as significant differences in leg length, can increase the risk of osteoarthritis in the hip and knee.
Knee degeneration develops slowly and progresses gradually, presenting with the following symptoms:
1. Pain: In the early stages of knee osteoarthritis, the pain is mild and felt during walking, climbing stairs, or standing for long periods. It usually subsides with rest. The pain is typically felt on the inner side of the knee, where the knees are closest together, although it may also be felt in the front or outer side of the knee. As the disease progresses, the pain becomes bothersome even at rest and can eventually interfere with sleep.
2. Tenderness: Pain is felt when touching the affected area.
3. Stiffness: Stiffness is usually felt in the morning after waking up or after periods of rest and inactivity. The knee joint does not move as easily or smoothly.
4. Reduced Range of Motion: As osteoarthritis progresses, the patient may not be able to fully bend or straighten the knee.
5. Crepitus: A painful grinding or cracking sensation when bending or straightening the knee.
6. Bone Spurs: These may be felt around the joint.
7. Deformity of the Knees: The most common deformity is the knees moving apart (genu varum).
8. Changes in Gait: In severe cases, the gait may become duck-like, with excessive swaying of the torso from side to side while walking.
The diagnosis of knee osteoarthritis or degeneration is based on the patient's history and a clinical examination by a doctor. Sometimes, doctors use simple X-rays, blood tests, or, in more complex cases, MRI to confirm the diagnosis or rule out other causes of joint pain.
Currently, the underlying process of knee degeneration cannot be reversed, but the symptoms can be significantly controlled, and its progression can be prevented. Exercise and weight control are the most important ways to manage the symptoms of knee joint degeneration. Patients should also make lifestyle changes, such as avoiding sitting cross-legged or on their heels and using a chair instead. They should limit the use of stairs and, if possible, use a Western-style toilet. Sometimes, they may need to use a cane or special insoles or knee braces.
The use of Thermo-Magnetic Arthronis knee braces and local heat therapy in the painful knee area is one of the effective methods recently discovered and used. Clinical reports indicate that the rate of improvement and pain reduction is significant one month after continuous use of these braces, with up to 90% improvement after three months, allowing the individual to regain full mobility. However, ongoing care and continuous use of this treatment method are necessary. These braces are available under the brand name Spilawizer in medical supply stores. Heel wedges may also be effective in treating knee osteoarthritis. Evidence suggests that the use of lateral heel wedges reduces the need for non-steroidal anti-inflammatory drugs (NSAIDs). Similar evidence indicates that braces and lateral wedge insoles may have a slight beneficial effect. These can be custom-made and purchased from specialty stores for osteoarthritis pain.
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Many complementary and alternative treatments have been used with varying success for treating knee degeneration. Glucosamine and chondroitin supplements have been marketed as disease-modifying options since the 1990s. A double-blind RCT showed minimal benefit from using glucosamine with chondroitin in participants with mild knee osteoarthritis. However, greater benefits were observed in individuals with moderate to severe pain. Glucosamine is safe, but its benefits are variable. Chondroitin does not reduce pain from knee or hip osteoarthritis.
The benefits of acupuncture are unclear. A meta-analysis showed no clinically relevant improvement in pain or function scores with acupuncture compared to sham acupuncture. However, in the short term (six weeks) and long term (six months), patients who received acupuncture or sham acupuncture felt better than those who received usual care. Another study found that six months of traditional Chinese acupuncture treatment reduced pain scores and improved function by an average of 40% compared to sham acupuncture or no treatment.
Supplements such as S-adenosylmethionine (SAM-e), ginger (Zingiber officinale), or turmeric (Curcuma longa) have also been promoted for treating osteoarthritis. A meta-analysis of RCTs found that SAM-e was as effective as NSAIDs in reducing pain and disability, with a better safety profile. Patients who took 255 mg of ginger extract twice daily experienced pain reduction (63% compared to 50% in the placebo group).
Pharmacological treatments for knee degeneration can be categorized as topical, oral, or intra-articular. Topical treatments avoid many of the side effects associated with systemic medications. A review of placebo-controlled trials on 0.025% capsaicin cream (Zostrix) concluded that it was statistically more effective than placebo but less effective than topical NSAIDs. Topical NSAIDs were superior to placebo in relieving pain but only for the first two weeks of treatment. Topical NSAIDs were even less effective than oral NSAIDs in the first week of treatment.
Many oral medications are available for managing pain from knee degeneration. Acetaminophen is the preferred drug in the American College of Rheumatology guidelines. It is more effective than placebo in treating arthritis pain. Liver toxicity is very rare, although caution is advised in patients who consume alcohol daily. Patients taking 3 to 4 grams of acetaminophen daily should have regular kidney and liver function monitoring. NSAIDs are slightly superior to acetaminophen in improving knee and hip pain in patients with osteoarthritis, especially those with moderate to severe pain.
Cyclooxygenase-2 (COX-2) inhibitors may play a role in treating osteoarthritis. Celecoxib (Celebrex) is the only remaining COX-2 inhibitor prototype, as rofecoxib and valdecoxib were withdrawn from the market due to adverse cardiovascular effects. However, celecoxib is also associated with an increased incidence of myocardial infarction and stroke. A systematic review found that while celecoxib use led to symptom control similar to other NSAIDs and did not reduce the risk of serious gastrointestinal side effects, patients were less likely to discontinue celecoxib due to gastrointestinal effects. Although the use of COX-2 inhibitors for treating osteoarthritis does not increase the risk of side effects compared to other NSAIDs, it may not offer significant benefits.
Opioids may also play a beneficial role in treating knee degeneration. The American College of Rheumatology guidelines support the use of opioid therapy when other treatments are ineffective or inappropriate. Tramadol (Ultram), with or without acetaminophen, reduces pain intensity, alleviates symptoms, and improves function. Tramadol increases the risk of seizures, especially in patients who consume alcohol. A recent guideline from the American Geriatrics Society recommends that all older patients with moderate to severe pain or reduced quality of life be considered for opioid therapy. However, the risk of addiction exists in these patients. Propoxyphene, which was withdrawn from the market in November 2010, should be avoided, as it is no more effective than acetaminophen and is associated with more side effects.
Intra-articular corticosteroid injections may provide short-term symptom relief in patients with knee degeneration, with a low risk of side effects. A systematic review of 28 clinical trials showed a significant reduction in short-term pain and improvement in patient self-assessment with intra-articular corticosteroid injections compared to placebo injections. However, there is no good evidence of long-term improvement. The exact mechanism of action is unknown, but it is believed that corticosteroids inhibit the accumulation of inflammatory cell lines, reduce prostaglandin synthesis, inhibit leukocyte secretion from synovial cells, and reduce interleukin secretion from the synovium. The usual dose for knee injections is 40 mg of triamcinolone acetonide (Kenalog), which may require two or three treatments.
Intra-articular hyaluronic acid injections (e.g., Synvisc, Euflexxa) are minimally effective for osteoarthritis. Although these drugs are marketed as potential disease-modifying agents, no study has shown that they alter the course of the disease. Synovial fluid is an ultrafiltrate of plasma modified by the addition of hyaluronic acid, which is produced by the synovium. In individuals with osteoarthritis, hyaluronic acid is reduced and compromised. It is believed that exogenous intra-articular hyaluronic acid supplementation supports and restores the viscoelastic properties of synovial fluid. However, a meta-analysis found that studies showing benefits from intra-articular hyaluronic acid injections were poorly designed or industry-supported, while other studies showed no clinically significant improvement in function.
Injection |Knee Osteoarthritis or Degeneration of the Knee Joint
Arthroscopic surgery is not a suitable treatment for knee degeneration unless there is evidence of loose bodies or mechanical symptoms such as locking, giving way, or catching. Two well-designed RCTs showed no benefit from arthroscopic surgery for treating knee osteoarthritis.
Total knee replacement should be considered as a last resort. According to the American Academy of Orthopaedic Surgeons, the primary indication for total knee arthroplasty is relief of pain from knee osteoarthritis when non-surgical treatment has been ineffective. The dissatisfaction rate for total knee replacement is 4.5% among patients.
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