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Treatment and Care Questions & Answers

If I’m not ready for knee surgery, does it really make sense to see a specialist, or can I stay with my primary care doctor?

Dr. DiNubile's response: 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 the full spectrum of treaments. Some orthopaedic surgeons’ entire practice is devoted to knee problems, and they might even offer more suggestions for you.

More Treatment & Care Questions

I’m a 45-year-old ex-jock who badly injured my knee playing high school football. It’s been scoped several times for cartilage tears and “cleanouts,” but my X-rays now show moderate osteoarthritis. I’ve been avoiding activities and sports and have gained considerable weight. I’ve tried cortisone shots, but they say I’m too young for a knee replacement. What else can I do? What are my other options?

Dr. DiNubile: Like many active individuals 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.

How do you decide whether to give your patients a steroid injection or Synvisc-One?

Dr. DiNubile: 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 which can help get the patient active again.

I have moderate osteoarthritis in my left knee. A friend recommended seeing a physical therapist (PT). Do you think it could help?

Dr. DiNubile: Physical therapy can be very helpful for individuals 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.

Is it a good idea to wear a knee brace all the time? It feels like it helps with my osteoarthritis, but a friend mentioned that it might be better to let my knee go without it sometimes.

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 individuals 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 individuals 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.

My primary care doctor took an MRI and sent me to an orthopaedic surgeon because he thought I might need arthroscopic surgery. But the surgeon disagrees. He says it won’t help my osteoarthritis knee pain enough. Who is right?

Dr. DiNubile: I suspect that your orthopaedic surgeon is correct on this one. Orthopaedic surgeons specialize in problems with muscles, bones and joints. Thus, they 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 individualize 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.

I’ve been taking prescription naproxen for my osteoarthritis knee pain for a few years. At my last doctor visit, we increased the dose since my knee’s been feeling a little worse. I’ve heard these pills can cause stomach or heart problems. Should I be worried?

Dr. DiNubile: Naproxen is an effective non-steroidal anti-inflammatory drug (NSAID) that also helps reduce pain. 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 musuloskeletal 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 does 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.

I’ve had osteoarthritis in my left knee for a couple of years. The pain seems to come and go. My doctor says I should rest and take over-the-counter pain pills when the pain gets bad. Is there anything else I should be doing? I’m worried about the arthritis getting worse.

Dr. DiNubile: It’s not unusual for osteoarthritis related symptoms to come and go. If the pain is intermittent and tolerable, then it’s certainly reasonable to do exactly what your doctor suggested: use over-the-counter medications like acetaminophen or ibuprofen and also cut back your activities — especially those that seem to irritate the knee. This is a good strategy for intermittent mild symptoms, but if you’re having more problems than that, you should talk to your doctor about other options that can give you more sustained relief. Resting too much, being sedentary and avoiding activities is not good for your overall health — and in the long run it is not good for your knee either. Also, even over-the-counter medications, especially if taken for extended periods of time, can be problematic. Your doctor might recommend other pill-free options for your knee osteoarthritis such as an injectable viscosupplement, like Synvisc-One, which can provide up to six months of osteoarthritis knee pain relief. Arthritis can indeed progress over time, and one of the best ways of trying to avoid that is to stay active so that you can maintain a healthy weight and keep your legs strong.



PLEASE NOTE: The views presented herein are solely those of Dr. DiNubile, Orthopaedic Surgeon. Sanofi does not endorse Dr. DiNubile or his book, FrameWork. Dr. DiNubile is a paid advisor for Sanofi. Be sure to consult with your own doctor before starting any exercise program or health regimen.

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Dr. DiNubile is an Orthopaedic Surgeon specializing in Sports Medicine in private practice in Havertown, Pennsylvania, and is a Clinical Assistant Professor of the Department of Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. DiNubile has been chosen in "Best Doctors in America" as well as "Guide to America's Top Surgeons."

He is the author of the bestselling book, Framework—Your 7 Step Program for Healthy Muscles, Bones & Joints (Rodale) and is Executive Producer and host of the award winning national PBS television special, Your Body's FrameWork.

Indication

Synvisc-One® (hylan G-F 20) is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics, e.g., acetaminophen.

Important Safety Information for Synvisc-One

Before trying Synvisc-One, tell your doctor if you have had an allergic reaction, such as swelling of the face, tongue or throat, respiratory difficulty, rash, itching or hives to SYNVISC or any hyaluronan-based products. Allergic reactions, some which can be potentially severe, have been reported during the use of Synvisc-One. Should not be used in patients with an infected knee joint, skin disease or infection around the area where the injection will be given, and should be used with caution when there is swelling of the legs due to problems with venous stasis or lymphatic drainage.

Synvisc-One is only for injection into the knee, performed by a doctor or other qualified health care professional. Synvisc-One has not been tested to show pain relief in joints other than the knee. Tell your doctor if you are allergic to products from birds – such as feathers, eggs or poultry – or if your leg is swollen or infected.

Synvisc-One has not been tested in children (≤21years old), pregnant women or women who are nursing. You should tell your doctor if you think you are pregnant or if you are nursing a child.

Talk to your doctor before resuming strenuous weight-bearing activities after treatment.

The side effects sometimes seen after Synvisc-One include (<2% each): pain, swelling, heat, redness, and/or fluid build-up in or around the knee. Tell your doctor if you experience any side effects after treatment with Synvisc-One.

 

View the Complete Prescribing Information for Synvisc-One

 

Indication

SYNVISC® (hylan G-F 20) is used to relieve knee pain due to osteoarthritis (OA). It is for patients who do not get enough relief from simple painkillers such as acetaminophen, or from exercise and physical therapy.

Important Safety Information for SYNVISC

Before trying SYNVISC, tell your doctor if you have had an allergic reaction, such as swelling of the face, tongue or throat, respiratory difficulty, rash, itching or hives to SYNVISC or any hyaluronan-based products. Serious allergic reactions have been reported. Should not be used in patients with an infected knee joint, skin disease or infection around the area where the injection will be given, or circulatory problems in the legs.

SYNVISC is only for injection into the knee, performed by a doctor or other qualified health care professional. SYNVISC has not been tested to show pain relief in joints other than the knee. Tell your doctor if you are allergic to products from birds - such as feathers, eggs or poultry - or if your leg is swollen or infected.

SYNVISC has not been tested in children (≤21years old), pregnant women or women who are nursing. You should tell your doctor if you think you are pregnant or if you are nursing a child. Talk to your doctor before resuming strenuous weight-bearing activities after treatment.

The side effects sometimes seen after SYNVISC include pain, swelling, heat, redness, and/or fluid buildup in or around the knee. These reactions were generally mild and did not last long, but in rare occasions these side effects were more severe. The most commonly occurring adverse events outside of the injected knee were rash, fever, nausea, and headache.

View the Complete Prescribing Information for SYNVISC

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Important Safety Information: SYNVISC and Synvisc-One are contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the target knee.