I recently saw someone in my office that was visiting from out of town. She has pretty bad knee arthritis but was scared to have knee replacement surgery. She has been dealing with her pain and limited function by taking some medication and some supplements and has started using a cane to help with her balance. She expressed some frustration to me about how her doctor back at home treated her. He had suggested to her that she needed to have knee replacement surgery and when she was reluctant to proceed with that, he made her feel like she was wasting his time.
As a surgeon myself, I spend time in the operating room and around other surgeons so I understand how they think and how they approach problems. Surgery is a very specialized skill and most surgeons feel like they are helping patients most when they are doing surgery.
If all you have is a hammer, everything looks like a nail.
After all, not everyone can do surgery, so if that is something I, as a surgeon, can do to help fix a problem, isn’t that the best use of my time, and the most helpful think I can do for my patients? A family doctor can write a prescription, do an injection, or send someone to physical therapy, but they cannot perform surgery. The problem with this logic, is that there is sometimes a disconnect, a breakdown in communication, between a patient, their family doctor, and the surgeon. Family doctors are able to help patients with a wide variety of medical conditions and the available treatments are changing all the time. New drugs, new surgical procedures, new therapies are developed every year and with experience we learn better who these treatment help best. I cannot imagine trying to stay up to date with all the different things that are changing in medicine all the time. I struggle to keep up with just the orthopedic innovations and new options. My point in all this is that a surgeon should remember that he is a doctor first and foremost. His duty is to provide the best care for his patient, not just perform surgery because he knows how to do that.
So I spent some time explaining to this patient all the available options for treating knee arthritis. She was very appreciative and it seemed like I offered many things that she had not heard before or didn’t fully understand the role of some of these treatments. So here is a broad overview of the different treatment options available for knee arthritis. Surgery is a very effective solution but that doesn’t mean that it is the only thing that works to treat the problem.
- Anti-inflammatories - this can be OTC medications like Advil or Aleve, an anti-inflammatory diet with herbs like Tumeric and willow bark, topical creams and ointments, essential oils, or prescription medications.
- Activity Modifications - standing and walking put stress on the knee. Running and jumping increase that stress. Stairs are also difficult on arthritic knees. Identifying those activities that irritate the knee and avoiding them (temporarily), or modifying how you do things to minimize these activities can reduce pain. This can be an effective short term strategy but may cause problems if prolonged for an extended period of time.
- Exercise and Physical Therapy - Pain makes activity more difficult and many with pain will decrease their activity level over time. This reduced activity leads to muscle weakness and weak muscles lead to more stress on the bones and joints which can increase the pain. Quad weakness is a common problem with knee arthritis. While general exercise like walking is good for overall health, it does not really do much to strengthen a weak quad muscle. Exercises specific for quad strengthening include squats, lunges, leg press, and knee extensions. A home exercise program can be very effective if done consistently. Working with a physical therapist tends to get better results because they will push you harder than you tend to push yourself and they can recognize things that might be slowing your progress and help you correct them.
- Injections - cortisone injections can reduce inflammation in the knee and this improves function and lessens pain. Cortisone injections for knee arthritis is generally considered safe about every 3 months. If they are effective, this can be used for several years to delay the need for surgery. If cortisone does not provide adequate relief, there are other types of injections (visco-supplementation and Platelet Rich Plasma) that can be done as well. These injections sometimes provide better or longer lasting relief than cortisone but are more expensive.
- Bracing - Arthritis often affects certain parts of the knee more than others. Wearing a brace that shifts the pressure and stress from the painful part of the knee to other less painful parts can reduce pain and improve function. This requires a very specific type of brace not generally available at a store or online. The brace needs to be an unloader brace. For people that stand and walk a lot during the day they can be quite helpful.
- Arthroscopic surgery - once you have developed significant arthritis in the knee, arthroscopic surgery is not likely to help. It is appealing to both patients and surgeons to sometimes consider this, simply because it is a relatively simple surgery, it is outpatient, and the recovery from surgery is not that difficult or lengthy. I have done this surgery before for patients that were not ready for the full knee replacement surgery but wanted to do something to reduce their pain. Sadly, it rarely works to provide any long lasting relief. Except in very rare situations, it is probably a waste of time and money to do arthroscopic surgery for knee arthritis.
- Knee Replacement - the last step in managing knee arthritis is a knee replacement. This is a very effective surgery and the results continue to improve as we develop better tools and techniques. Most patients are in the hospital for 2 to 4 days and go home on a cane or walker. Driving is allowed as pain and strength improve over the first 6 weeks or so. Return to work varies depending on the type of work - office work is quicker than construction or physical labor.
I know that was a quick overview without much detail but that is an overall summary of the different treatments recommended for knee arthritis. In the future I will come back and detail each of these strategies in more detail.