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.
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.
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.
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.
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.
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.
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.
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.
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.