Arthritis of the knee

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Many types of arthritis affect the knee; therefore, when a patient comes in with knee pain, the first and most important task is to take a careful history and do a careful examination.

Things that might give you a clue are the age of the patient, the presence or absence of swelling, redness, or heat, and whether a family history of arthritis exists. Also, what was the patient doing when the pain came on? How long has the patient had the problem? Are there any other areas that hurt? Is there any locking, clicking, or "give-way" in the knee? Any night pain?

A history of kidney stones or inflammation of the big toe might be a clue to gout. A peculiar rash may signify Lyme disease. Multiple small joint swelling can point to rheumatoid arthritis.Locking suggests a mensicus tear.

On examination it’s important to examine the patient from the top of their heads to the bottoms of their feet. Eye inflammation may be a tip off to Reiter’s disease. A scaly rash on the bottom of the feet may signify psoriatic arthritis. An enlarged spleen or swollen lymph nodes could point towards lymphoma.

After that is all done then treatment can be instituted.

Osteoarthritis (OA) is the most common type of knee arthritis. This type of arthritis is also called wear-and-tear arthritis or degenerative joint disease. The fortunate thing is that most people with knee arthritis who present to a rheumatologist have osteoarthritis (OA).

OA is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage is worn away by knee arthritis, bare bone is exposed within the joint.

Other varieties of arthritis that may affect the knee, as mentioned earlier, include: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Reiter’s disease, Lyme disease, septic arthritis, gout, and pseudogout. These types of arthritis are more inflammatory and affect a somewhat different age group.

Knee arthritis due to OA typically affects patients over 40 years of age, although it may be symptomatic in younger people. Evidence suggests it may begin much earlier in people predisposed to the disease- perhaps as early as the teen years. It is more common in patients who are overweight. Weight loss reduces the symptoms associated with knee arthritis. There is also a genetic predisposition of this condition, meaning knee arthritis tends to run in families. Other factors that can contribute to developing knee arthritis include trauma to the knee, meniscus tears or ligament damage, and fractures to the bone around the joint.

Knee arthritis symptoms tend to progress as the condition worsens. Knee arthritis symptoms tend to wax and wane. Often patients report good days and bad days or symptom alteration with weather changes. This is important to understand because symptoms of arthritis on any given day may not accurately represent the overall progression of the condition.

The most common symptoms of knee arthritis are:

• Pain with activities
• Limited range of motion
• Stiffness of the knee
• Swelling of the joint
• Pain at night
• Tenderness along the joint line
• A feeling the joint may "give way"
• Deformity of the joint (knock-knees or bow-legs)

Evaluation of a patient with knee arthritis should begin with a physical examination and X-rays. X-rays sometimes will indicate the presence of complicating problems such as calcification inside the joint pointing towards a condition known as pseudogout.

Early on, magnetic resonance imaging is more helpful in diagnosing disease.

Diagnostic ultrasound can also be useful.

X-rays can serve as a baseline to evaluate later examinations and determine progression of the condition.

Treatment of knee arthritis should begin with the most basic steps. Not all treatments are appropriate in everyone.

Weight loss is important, yet it is often neglected by both the patient as well as the doctor. The less weight the joint has to carry, the less painful activities will be.

Limiting certain activities may be prudent, and learning new exercise methods may be helpful. Avoidance of impact loading exercises is mandatory. Aquatic exercise is a good option for patients who have difficulty exercising.

Use of a cane or a single crutch in the hand opposite the affected knee will help decrease the load placed on the arthritic joint.

Strengthening of the muscles around the knee joint (the quadriceps and hamstrings) may help decrease the burden on the knee. Preventing atrophy of the muscles is an important part of maintaining functional use of the knee.

Medications including analgesics and anti-inflammatory medicines (NSAIDs) sometimes help with pain and inflammation. These are available in both oral as well as topical forms.

Cortisone injections may help decrease inflammation and reduce pain within a joint. They should not be given more often than 3 times per year.

Viscosupplements are lubricants that may be effective for pain and may also help retard progression of disease. Viscosupplements may delay the need for knee replacement surgery.

Glucosamine and chondroitin supplements appear to be safe and might be effective for treatment of knee arthritis. Research into these supplements is ongoing.

Exactly how effective knee arthroscopy is for treatment of arthritis is controversial. For some specific symptoms, it may be helpful.

Braces are making a comeback. Certain new types of braces are able to “unload” the narrowed compartment in patients with knee arthritis. This helps reduce pain and allow easier and less painful walking.

Knee osteotomy- cutting a wedge of bone out of the tibia to align the leg better- may be an alternative to more invasive surgery. While most patients are not good candidates for this alternative to knee replacement, it can be effective for young patients with limited arthritis.

Total knee replacement surgery is a procedure where the cartilage is removed and a metal & plastic implant is placed in the knee.

Partial knee replacement surgery is also called a unicompartmental knee replacement. This is replacement of one part of the knee. It is a surgical option for the treatment of limited knee arthritis.

A better option than surgery is stem cell therapy. In this procedure, a small needle is inserted into the iliac crest of the pelvis (near the hip) and bone marrow is aspirated from the patient. Bone marrow contains a large number of stem cells. The stem cells are then concentrated using a special technique.Stem cells from fat are also harvested simultaneously. Also, platelet rich plasma is obtained by drawing a specimen of the patient's blood and then putting the blood in a special centrifuge. Platelets are cells that contain numerous growth factors. Using a combination of diagnostic ultrasound as well as mini-arthroscopy, a small needle is then inserted into the joint and the bare bone is selectively injured in order to create a "homing" spot for the stem cells. Once the homing procedure is completed, the stem cells and the platelet rich plasma are then injected into the joint (usually a hip or knee). Studies have demonstrated regeneration and regrowth of cartilage.

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