Dr. Dinubile: When you have knee osteoarthritis, one of the common complaints is that it hurts too much to exercise. But exercise done right shouldn’t be painful. With certain exercises, you have to stick with them and build strength and flexibility back into your joints — with the end result being improved function and less pain. There may be a little discomfort, but once people know they’re not doing harm, they can usually work through it.

Dr. Dinubile: Overall, exercise is wonderful for joints with osteoarthritis, but not all exercise is created equal. In general, patients with knee osteoarthritis should employ lower-impact, aerobic-type activities such as walking, cycling, elliptical training or water-based exercises. Of all the options, I think cycling is one of the best for helping to build your thigh muscles. That's why stationary cycling is a mainstay of knee rehabilitation following knee injury or surgery.

Walking is also good, but some individuals with more advanced osteoarthritis have difficulty even with that. So for them I recommend water aerobics or swimming or even using a stationary bike or elliptical machine.

Strength training is also important for osteoarthritis, but one must be careful not to overload the joint. Check with your doctor or physical therapist about safe and effective exercise routines that are ideal for osteoarthritis sufferers.

For longer-term relief, Synvisc-One may also be a very good option for you. It helps to lubricate the knee joint and provide pain relief for up to six months. Many of my patients get good results from it and most importantly finding relief from osteoarthritis knee pain helps them start exercising and moving again, which is the best thing you can do for arthritis.

Dr. Dinubile: Absolutely. If you have early-stage osteoarthritis, exercise is important in terms of maintaining joint health and even preventing progression. If you have late-stage osteoarthritis, it's still a good idea. It will improve your function and even reduce pain levels if you stick with it. Even if you need knee replacement surgery, you're going to do better if you're in better shape. You're going to come out of the surgery and recover quicker, with a better overall result.

Dr. Dinubile: As an orthopaedic surgeon, I'm often asked if running causes arthritis. Pounding the pavement, mile after mile, year after year — you'd think it would cause wear on your hips and knees, just the way tires on your car wear out as the miles accumulate.

The truth is that running does not cause osteoarthritis in healthy knees. Now, runners are usually very glad to hear that statement, until they hear my next one: If you have osteoarthritis, running will make it worse.

Running is a high-impact activity generating forces 5-7 times body weight on your knees and hips. If you already have osteoarthritis, it will accelerate the wear, damaging your joints further. If you have osteoarthritis and are overweight while pounding the pavement, you are even more likely to worsen the wear process.

Dr. Dinubile: Stretching primarily helps the muscles, while range of motion (ROM) exercises target the joints. They are both extremely important for those with knee osteoarthritis.

Stretching is perhaps the most neglected part of our workouts. Most of us need to stretch more, especially as we age. It's best to stretch after a good warm up and especially after your workout is concluded.

The purpose of warming up is to get blood flowing to your muscles and to raise your body temperature. A warmed-up muscle is much more likely to behave elastically when stretched and less likely to be injured or strained.

Your muscles and tendons are a lot like taffy. When taffy is cold, it is quite brittle and can be broken into many pieces. Once warmed, it's gooey and elastic. A warm up can be simply one or two minutes of calisthenics like jumping jacks, running in place or a brief ride on a stationary bike. Lower impact activities, like bike riding, are better if you have kneeosteoarthritis.

Joint ROM exercises are especially important for those with knee osteoarthritis. They help keep mobility in the joint and prevent stiffness and motion loss that is so common with osteoarthritis. To improve or maintain joint mobility, gently and slowly flex (bend) the joint as much as possible and hold 10–20 seconds, then extend (straighten) the joint and hold for another 10–20 seconds.

Stretching and ROM exercises should be static, which means no bouncy movements.

Dr. Dinubile: Being active in sports and exercise is extremely important for maintaining your overall health, especially as you age. Sometimes being active in certain sports can be a challenge if you have osteoarthritis in your knees. Golf and tennis are good sports for someone with arthritis. It is unlikely that they will make your arthritis any worse, and overall might make you feel better. If you want to stay active in sports, you should try to keep your weight down and keep your legs strong. Spend a little time warming up before activity and afterwards, stretch and/or use ice on your knee. Some individuals do better if they try some acetaminophen or ibuprofen before and/or after activities. Check with your doctor about using these or other medications around activity. Also, if walking bothers you, try using a cart when you golf. If singles tennis irritates your knees, try doubles tennis on a softer surface. If symptoms persist with your attempts to stay active in sports or fitness, again, talk to your doctor. There are treatments, like Synvisc-One that can reduce your knee pain, and could help you participate more comfortably in the activities you enjoy.

Dr. Dinubile: In general, your muscles can’t tell the difference between free weights and machines. You can even build strength with elastic tubing when used as resistance, something that has gotten very popular in recent years. Muscles will grow and strength will improve when they are called upon to do more than they do in everyday life. Both free weights and machines can provide the stimulus needed to accomplish this and build muscle. It really comes down to what you enjoy doing, and what you are willing to stick with over the long haul.

Also, what is available to you? For upper body training, I think both free weights and machines can be quite easy, and both can be very effective if done properly. In terms of your legs, I think it’s easier to target specific muscle groups if you have the correct machines available to you. Otherwise you need to use free weights or tubing to provide resistance, and this can get a little tricky at times.

Regardless, don’t forget to include exercises for your core, which includes the abdominal, lower back, pelvis and hip area. It’s helpful to do core-type exercises on a stability ball, which looks like an oversized beach ball.

Strength training is an essential component of an overall-balanced exercise program, and one that is all-too-often neglected — especially in women and older adults. Being stronger helps you remain functional with age. It prevents injury, and having some extra muscle on your frame raises your metabolic rate, thus helping with weight control.

Dr. Dinubile: Swimming and other water workouts are one of the absolute best things you can do if you have knee osteoarthritis. This is because you're somewhat "weightless" in the water, almost like an astronaut in space, and your movements are slowed down, so you're much less likely to injure yourself.

Kicking in the water should not hurt your knees, but I recommend that you gradually increase your program and see how you tolerate things. And while you're in the pool, don't just limit yourself to swimming up and down lanes. There are endless options for exercise in the pool such as water walking, aqua aerobics and in-pool strength training and stretching routines.

Swimming is an excellent overall activity, especially for individuals with knee osteoarthritis, but remember that it doesn’t provide everything you need — don't forget to add strength training and stretching to round out your routine.

Dr. DiNubile: Strong thigh muscles are essential for healthy, happy knees.

The quadriceps muscle (front of the thigh) is a very important protector of the knee, and it acts as shock absorber. To build that muscle you need to do very specific strengthening exercises. Walking, or even running will not build that thigh muscle. This is especially important if you have had an injury, surgery, arthritis or any source of pain in your knee that can lead to loss of muscle; otherwise known as atrophy.

Muscles also tend to weaken and disappear with advancing age, especially your thigh muscle. Once muscle is lost — something quite common with OA of the knee — it will not come back on its own. Your best bet is to do specific strength training exercises for your legs.

I often have patients who say to me, “I am on my feet all day, my legs should be strong enough.” Their intuition is completely wrong. Standing and walking will not build or rebuild those important thigh muscles. A few sessions with a physical therapist can go a long way in getting you back on track with strong legs.

Dr. Dinubile: Your story is very typical for someone with knee osteoarthritis who is trying to start or maintain an exercise program. We all know that regular exercise is very important, but when you're in pain it's difficult to get active. The less active you are the more likely you are to gain weight, and that's not good for your knees. Studies have shown that for every pound a person is overweight, four to five pounds of extra pressure is added to each knee during walking.

There are ways that you can try to become more active — even with osteoarthritis. Sometimes working with a physical therapist can get you going in a safe, effective manner. You also need to spend time building muscle and strengthening your legs with appropriate exercises. If the pain is still limiting you, then you should speak with your physician about treatments to lessen the pain to help get you out of this rut. Once you break this pain cycle, then you can get more active and begin exercise. This will give you more lasting pain relief and improvement of function.

Dr. DiNubile: Carrying extra weight is problematic for your knees. Small amounts of weight are amplified across your joints, which can be damaging. If you're running or jumping, the forces across your joints are even higher. This is because for each extra pound you carry, your knees feel four or five pounds. So, if you're 20 pounds overweight, your knees think that you are carrying 80 to 100 extra pounds!

Even a small amount of weight loss can go a long way in keeping your knees healthy. Losing just 10 pounds has been shown to make a difference in slowing down or even halting the progression of knee osteoarthritis. By keeping your weight in a more ideal range, you will feel better, function better and hopefully your osteoarthritis can be kept in check.

Dr. Dinubile: Night pain is a very common complaint in individuals with knee osteoarthritis or inflammation. There are several theories as to why pain is amplified during the night, but no one knows the exact reason for this phenomenon.

Restful sleep is very important in maintaining overall health, so anything that routinely interferes with sleep is not good for your health. Try to determine what you may be doing earlier in the day (or even the day before) that may be provoking your knee. Sometimes this takes a little trial and error or detective work. You can then modify your activities accordingly.

Your physician may also suggest remedies that can improve your situation. Some patients benefit from heat or ice in the evening, or even a little physical therapy. Others do well with an evening medication such as acetaminophen or an NSAID like ibuprofen, but I try to avoid prescribing narcotics or sleeping pills. I have had success in alleviating night pain, stiffness and other symptoms of knee osteoarthritis with the use of viscosupplement injections like Synvisc-One.

Be sure to talk to your doctor about nighttime symptoms. Be proactive — don’t take them lying down!

Dr. Dinubile: Stairs can be a major challenge for anyone with osteoarthritis of the knee. This is because your knee has to work harder when ascending and descending stairs, putting more pressure on the already-worn joint surfaces. Also, individuals with knee osteoarthritis tend to have weaker supporting leg muscles which means that there is less power to negotiate stairs. Your leg muscles also act as important shock absorbers, so weaker muscles mean less protection for your vulnerable knees.

To improve your situation I would recommend daily strengthening exercises for your thigh muscles. A short course of physical therapy can be helpful in developing a program that is right for you. If you are overweight, losing even a few pounds lessens the load on your knees, especially on stairs. Also, trying not to carry heavy loads up and down all at once. Lean on the rail a little to cheat, until you get that leg strength improved.

Dr. Dinubile: One of the most common symptoms of knee osteoarthritis is stiffness. This occurs even in the early mild cases of knee osteoarthritis, as well as the more advanced stages of arthritis. It also seems to happen more after an individual has been sitting for a period of time, especially in a more cramped situation like a car or airplane. Remember, “motion is lotion” for your joints. The knee is no exception. Movement helps lubricate and nourish your joint surfaces. A knee joint with osteoarthritis is particularly susceptible to stiffness when it is held in one position for long periods. The solution is to try and keep moving. Take breaks as often as needed (usually every hour or so) to stop the car and move about.

Dr. Dinubile: Vacation and travels can be rough on your joints, especially if you have arthritis. Problems can start at the airport when all too often you’re walking around carrying heavy luggage. This puts added strain on your joints. Also, once you’re in Rome, you’ll probably be walking much more than your body is used to. Pack a little lighter in terms of your carry-on baggage so that you are not lugging things around the airport. If you take prescription medications or over-the-counter pills for your arthritis, be sure to bring extras as you may not be able to get what you need in Europe. Also, bring a freezer gel pack so that you can ice your knee at the end of a long day. Try not to over do it on any one day and allow for some rest stops along the way. If you’re having a significant flare-up the week before you leave, your physician can inject cortisone into your knee that will hopefully give you temporary relief and make the trip more comfortable. For a more chronic type of pain, you should talk to your doctor about a treatment like Synvisc One. A simple injection done in the office setting can provide up to six months of knee pain relief for osteoarthritis related pain which can make your trip more enjoyable. Ideally this would be done a few weeks before you leave so that the treatment has a chance to begin working. Have a great trip!

Dr. DiNubile: Your daughter is very wise to alert you about the potential health problems associated with over the counter (OTC) medications. Just because something is OTC does not mean that it is not without danger. Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen) are a prime example of this. The ones that are sold OTC are basically the same that you can get via prescription, only at a lower strength. If you are taking these continuously, you may be exposing yourself to health risks associated with these medications. They can be effective in the management of osteoarthritis, but in recent years, we as physicians have become more conservative with their use, especially longer term. Some individuals are more predisposed to problems with NSAIDs than others, and these problems can include gastrointestinal issues such as bleeding, problems with liver and kidney function and even cardiac issues. Most individuals tolerate NSAIDs just fine when taken properly, but everyone should be aware of the potential problems that can arise. If you need to take OTC medications like ibuprofen or other NSAIDs more than a few weeks at a time, even if you seem to tolerate them, you should bring this up with your physician or consider seeing an orthopedic specialist.

Dr. DiNubile: Exercise is essential not only for maintaining health, but also in the management of osteoarthritis. I applaud your interest in getting back into exercise and encourage it. With my patients, I believe that the relief that they got with treatments like Synvisc-One, was only the first step in getting them better. Once they start to feel relief, I think it is essential that they get back into a proper exercise program. With my patients, I usually ask them to take at least two days off after the injection and then monitor their response. If they start to feel better, then within a week I can let them start some easy lower impact exercise like walking, stationary cycling or water based exercise. I also instruct them on simple exercises to maintain strength and mobility around their arthritic knee. This helps keep them out of trouble with exercise. It is sometimes a challenge to find the right exercise routines that are tolerable for those with osteoarthritis. One mistake is to give up exercise completely and adopt a more sedentary lifestyle. In the short-term you might feel a little better sitting around doing nothing, but long term, your overall health and functional abilities will deteriorate. I would urge you to talk to your doctor, or physical therapist, about what type of exercises are best for you, and when you can ramp up that program.

Dr. Dinubile: Your primary care doctor can be very helpful in managing your knee osteoarthritis, especially in the earlier stages. However, specialists like orthopaedic surgeons and rheumatologists will usually offer a more comprehensive approach in managing your knee osteoarthritis, including the ability to review and discuss many of the newer therapies such as Synvisc-One. Some orthopaedic surgeons’ entire practice is devoted to knee problems, and they might even offer more suggestions for you.

Dr. Dinubile: Like many active indiv class="ans"iduals in your age group, you’re in that middle ground in terms of treatment options for your arthritic knee. Because you’ve already been through several surgeries, more arthroscopic surgery is not the answer unless something very specific occurs, like new torn cartilage. There comes a point when minor repeat procedures really don’t offer much. On the other hand, you are young for knee replacement surgery and hopefully your osteoarthritis is not yet at that point. Fortunately, there are some treatment options for you. It’s often a combination of elements that can help keep you active and comfortable, plus avoid knee replacement down the line. Keeping your weight down is essential. Every extra pound you carry puts significant weight on your joint. Your knee feels approximately five pounds for every extra pound that you carry during certain activities. Strengthening your leg muscles is also very important, especially your quadriceps muscle on the front of your thigh. Occasional steroid injections could be helpful, especially around times of significant flare-ups. But they are short-term solutions for reducing inflammation and generally last for only a few weeks. Also, too many steroid injections may be damaging to the articular cartilage or joint cushion in the knee.

For longer-term relief, Synvisc-One may also be a very good option for you. It helps to lubricate the knee joint and provide pain relief for up to six months. Many of my patients get good results from it and most importantly finding relief from osteoarthritis knee pain helps them start exercising and moving again, which is the best thing you can do for arthritis.

Dr. Dinubile: In my mind, Synvsic-One has really moved steroid injections to the sidelines. I look at steroid injections as a short-term fix for flare-ups or a very inflamed knee. Or for somebody who is in severe pain and needs a very quick fix, like for an event that weekend. On the other hand, I think of Synvisc-One as the long-term strategy for really dealing with the pain and getting the patient active again.

Dr. Dinubile: Physical therapy can be very helpful for indiv class="ans"iduals with knee osteoarthritis. The physical therapist (PT) will start by trying to quiet down some of your knee symptoms using modalities such as ice, heat or even electrical stimulation.

Also, and probably more importantly, they will place you on a proper exercise program that can help rebuild strength around your knee. Your muscles are the major shock absorbers for your knee joints. By improving the strength and control of your leg muscles, you can reduce the forces across the arthritic joint, and improve knee function.

Although a short course of physical therapy with the direct supervision of a PT can be very helpful, the most important thing would be for that therapist to give you a daily home program for you to continue indefinitely when your physical therapy sessions end. You might have a little discomfort with some of the exercises at first, but if you can tolerate that minor discomfort, there will be a big payoff with improved function and less pain around your arthritic knee.

Dr. Dinubile: Many patients find the use of a knee brace or knee sleeve helpful. With elastic or neoprene sleeves, it is really a matter of comfort. If you feel better with it on and that allows you to do more things comfortably, then by all means use it.

There's no harm in wearing it all the time, but most indiv class="ans"iduals find it difficult to wear a knee brace or sleeve all day. There are also custom, more rigid knee braces that are helpful for patients who are either knock-kneed or bow-legged and have significant arthritis.

These "unloader" braces can take pressure off the knee, but are not helpful for everyone, and they can be pretty expensive. Ask your doctor if you are a candidate, as they do require a prescription.

The best "brace" for your knee is your own muscles around the knee, and that is why exercise is so important for indiv class="ans"iduals with knee osteoarthritis. This is especially true for the quadriceps muscle on the front of the thigh. Whether you wear a brace or not, you should talk with your doctor or physical therapist about exercises you can do to strengthen the muscles that support your knee.

Dr. Dinubile: I suspect that your orthopaedic surgeon is correct on this one. Orthopaedic surgeons specialize in problems with muscles, bones and joints, and thus are probably more knowledgeable about your specific problem and the possible need for surgery.

That’s not to say that every orthopaedic surgeon is right every single time. I have a saying, “We don’t treat MRIs; we treat patients.” What it means is that findings on an MRI can sometimes be misleading, and treating physicians must correlate what is seen on the MRI with other factors.

For instance, a primary care doctor sees that there is a “torn meniscus” on the MRI and assumes that it absolutely needs surgery. While the MRI findings can be very important, they cannot be interpreted in isolation. As an orthopaedic surgeon who specializes in knee problems, I need to combine the findings from speaking to my patients, examining them, looking at their x-rays and looking at the MRI.

By putting all that information together I can usually indiv class="ans"idualize the advice that I give to each patient. This is especially true for those who have significant osteoarthritis. The MRI may show a meniscus or cartilage tear, but the bigger issue could be the arthritis, and those patients often do not respond to arthroscopic surgery. This underscores the need for standing X-rays in all adults, to help determine the true degree of arthritis before making any decision on MRI findings, or even before ordering an MRI.

If there is any question in your mind about who is right, I would suggest a second opinion with another orthopedic surgeon who specializes in the knee.

Dr. Dinubile: Naproxen is a very effective non-steroidal anti-inflammatory drug (NSAID) that also helps reduce pain. It is one of the many NSAIDS that are available, and it has one of the best safety profiles of the group. Some NSAIDS are sold over the counter and others are by prescription. They can be very effective in treating joint pain and inflammation secondary to arthritis.

However, there can be many unwanted side effects with NSAIDS — some quite serious. These include problems with your heart, stomach ulceration and bleeding, as well as kidney and liver issues. Also, some recent research suggests that NSAIDs may interfere with the healing of certain musculoskeletal issues like fractures and muscle or tendon tears.

In the past, we were much more liberal in prescribing NSAIDS for long periods of time. Now we try to use them sparingly and in lower doses for shorter duration. That said, some patients still need to be on these medications indefinitely to manage their arthritis pain.

If you are on NSAIDS for long periods of time, you need to be monitored by your physician. Be on the lookout for possible side effects like stomach irritation. Also, if you are on an NSAID for over six months, I recommend getting some laboratory blood work to make sure all your systems are working fine.

Dr. Dinubile: MRI technology is amazing because it provides information about the knee and other joints that we once couldn’t see without surgery. However, they don’t always show the whole picture. Regular X-rays provide very useful information and actually complement what you see on an MRI. In fact, the degree of arthritis is better determined on X-rays than on MRI scans. Your doctor is right in wanting X-rays. He or she may also ask for certain special views depending on what is found in a physical exam. X-rays of the knee are very useful, and I rarely ever make a final decision about treatment without seeing them.

Dr. Dinubile: “Flare-ups” are extremely common for individuals with osteoarthritis of the knee.  When you have osteoarthritis, your knee can be very temperamental. Inflammation of the joint can occur, something we call synovitis. Sometimes the reason for the flare-up is obvious, like being overactive, taking a long walk, dancing or playing some tennis.  Other times it seems to happen for no obvious or rational reason.

If you have a flare you should contact your doctor, who can usually manage your knee flare easily, and with some simple measures. He or she will probably recommend rest, and applying ice to your knee. Also, over-the-counter pain relievers like acetaminophen can help the pain, and NSAIDs (over-the-counter or prescription) can both relieve pain and reduce inflammation. Occasionally, a cortisone shot is needed to settle things down.

Viscosupplements can give a more lasting pain relief of osteoarthritis symptoms than cortisone. It is a very simple and quick procedure done in the office, with minimal or no discomfort, and it can provide a more lasting relief from your osteoarthritis knee pain. For longer-term relief, Synvisc-One may also be a very good option for you. It helps to lubricate the knee joint and provide pain relief for up to six months. Many of my patients get good results from it and most importantly finding relief from osteoarthritis knee pain helps them start exercising and moving again, which is the best thing you can do for arthritis.

Dr. Dinubile: Osteoarthritis of the knee is very common, and the good news is that most individuals who have it do not eventually wind up with knee replacements. Certainly, if the degree of arthritis is severe, and if symptoms are significant and not relieved by other options, a knee replacement could be the correct step. With mild ostoearthritis of the knee, your goals should be to try to prevent the arthritis from progressing, and in many instances this is certainly possible. The key is to keep your weight down and keep your legs strong. You should also avoid higher impact activities such as running.

Interestingly, even patients that have more advanced knee osteoarthritis do not all eventually require knee replacements. Some do not have enough symptoms to warrant knee replacement, while others find treatments that can delay or even avoid the need for knee replacement completely. There are many treatments for knee ostoearthritis, so don’t be afraid to try a few until you find one that works for you.

Dr. Dinubile: Having osteoarthritis in one knee does not guarantee that you'll have it in the other knee as well. Knee osteoarthritis has many causes. If you had an old injury to your right knee, and that was your predisposing factor for the development of arthritis, then you probably will not get it in your opposite knee. However, if you are bowlegged or knock-kneed, or were born with a risk factor for osteoarthritis, then you may be more likely to have it occur in the opposite knee. Talk to your physician about this, and he or she may want to get some X-rays of both knees to see if there are any predisposing factors or signs of early arthritis. If indeed you do have some early osteoarthritis in your opposite knee, which isn’t causing you pain, then prevention becomes very important. Your physician can outline a comprehensive preventive program, which would include things like weight management, activity modification and some leg exercises.

Dr. Dinubile: “Water on the knee” is the term used for a knee joint that has accumulated fluid or is swollen. Normally, your knee has only a few drops of clear, yellow fluid that acts as a lubricant and provides nutrients to the joint surface. Anything more than that implies that there is something wrong in the knee and you should get it checked. The lining of the knee joint, called the synovium, will release extra fluid when things are irritated. The knee will look a little full or bloated, and it may feel tight or even painful. Swelling can come from a variety of causes including injury, arthritis, infection, and certain medical conditions. It’s very common for individuals with osteoarthritis of the knee to develop some swelling, also known as an effusion, because of some inflammation that occurs in the knee. If your knee is swollen, the most important thing to do is to figure out the exact cause. Your physician can remove, or aspirate, the fluid from your knee, and the color and consistency of the fluid can often help determine what type of problem the knee is having. For example, blood in the knee is usually from a significant injury like a torn anterior cruciate ligament or a torn meniscus. If the fluid is a clear yellow, then it may be related to osteoarthritis. If the fluid is cloudy, there should be concerns about other conditions like infection, Lyme disease, or other rheumatologic issues.

Dr. Dinubile: There are many causes of osteoarthritis — from injury, to being overweight, to having problems with your alignment (knock-knees or bowlegs). We also now know that there are genetic predispositions to certain types of knee osteoarthritis. It does indeed run in families at times. However, just because a relative has osteoarthritis does not mean that everyone in the family will get it. Also, symptoms related to osteoarthritis can vary dramatically from one individual to the next, something we don’t really understand. Two individuals with the exact same amount of arthritis can have completely different experiences, with one having a lot of pain and the other being relatively pain-free. If you’re having symptoms you should talk to your doctor about what you can do to feel better. There are many options to improve your situation. Also, if arthritis runs in your family, you should do all you can to try to prevent it from occurring or worsening, such as staying fit and keeping your legs strong and your weight in a healthy range.