Knee arthritis is so prevalent in our population with at least 1 in 10 suffering from the problem when they hit their 50s. The problem gets more pronounced as patients age, but treatment options also become quite predictable and reliable.
The incidence of the problem is less in the younger population but from the treatment perspective, it is more difficult to treat younger patients as we are looking at treatment options that are predominantly short term, unpredictable and less reliable. With a complete cure and reversal not possible at the moment, we can choose from a wide range of treatment options ranging from physical therapy, drugs, injectable options to surgical management. Replacement surgeries, both partial and total knee replacement offer predictable long-term pain relief and mobility in older patients with advanced cartilage damage (grade IV).
For milder grades of arthritis (grades I - III), a variety of non-surgical and surgical (non-replacement) options exist which can be catered to the needs and demands of patients. This article would help readers know about non-surgical treatment options for dealing with pain due to mild to moderate knee osteoarthritis.
Physical Therapy/ Exercises:
Considering that cartilage has no nerve endings, most of the pain from arthritis come from different sources especially in the early phase. Pain comes from muscles and capsulo-ligamentous structures that stabilise and move the joint. Thus, exercises can have an extremely positive effect in the setting of early arthritis. Exercises help to keep the bodyweight under control thereby reducing the overall impact on the knee joint. It strengthens muscles and improves bone quality which improves pain relief and overall performance of arthritic joints. Exercises also help in loading the joint which is essential for cartilage survival and regeneration since joint cartilage gets its nutrition from diffusion. We typically prescribe both aerobic exercises which provide rhythmic controlled loading of the knee and strength training to achieve the desired benefits in younger patients with mild to moderate arthritis
Medicines are aimed to control arthritic pain and their effects can be best termed temporary.
Non-steroidal, anti-inflammatory drugs (NSAIDs) have been shown to work and provide effective pain control in osteoarthritis. Their long-term use can be associated with significant systematic adverse effects and is not recommended. Our strategy is to use NSAIDs to provide breakthrough pain relief temporarily when they experience exacerbations due to synovial effusions (excessive fluid collection in the knee due to synovitis), control subchondral bone edema (swelling) but avoid regular usage of these drugs on a long-term basis.
Oral chondroprotective agents such as chondroitin, glucosamine and hyaluronic acid were introduced with a lot of promise to reverse the arthritic process and help regenerate cartilage. These drugs, however, have failed to show promised results in arthritic patients and have been given up largely. These medicines are no longer recommended as first-line therapy for osteoarthritis.
A number of injectable therapies can be tried to control pain in knee arthritis. Injectable treatment options are capable of providing longer periods of pain relief and safety compared to oral NSAIDs. Available injectable therapies range from depot steroid formulations, Visco supplements to biological injections such as platelet-rich plasma (PRP) and stem cell preparations. These injections can also be combined to enhance their efficacy and to achieve longer periods of pain relief. They work best in younger patients with mild to moderate arthritis and suffer intractable pain which doesn’t get relieved by physical therapy and intermittent NSAIDs.
Less water-soluble depot steroids are capable of providing pain relief up to 6 months in select patients and can be used effectively though safety is a concern. Injectable steroids though safer than oral steroids should be used with caution in patients with diabetes and inflammatory arthritis.
Viscosupplementation with natural hyaluronic acid formulations helps improve synovial permeability, viscosity and increase lubrication to provide pain relief and improve stiffness in arthritic knees. They typically pain relief for periods up to 3 - 6 months very similar to depot steroids.
Platelet-rich plasma has been shown to be effective in tendon healing and might also have a role in providing pain relief in patients with osteoarthritis. Different PRP formulations are available with variable dosing options. Our preference is to use biologic injectable preparations for symptomatic young patients with early arthritis while steroid preparations can be opted for in older patients.
The strategy is to use leucocyte poor PRP in combination with viscosupplementation. Additional doses can be repeated depending on the response. In patients showing a positive response in terms of pain relief, we repeat doses at 2 weekly intervals for a maximum of 3 injections. Positive and long-term pain relief can be expected for up to a year.
Stem cells are another useful strategy to mitigate pain in osteoarthritis. Stems cells can recruit new cartilage cells to slow down the arthritic process and release growth factors to control inflammation and pain.
They are chondroprotective and provides immuno-modulation for pain relief. Stem cells can be safely harvested from patient's own bodies, concentrated and then injected into the area of concern. They are capable of providing longer pain relief and long-term beneficial effects in a young patient with early arthritis.
They are especially useful in patients with chondral defects, post - meniscectomy patients and can be effectively combined with joint preservation surgeries for arthritis.
- Dr. Ashok S. Gavaskar, MBBS, MS Orth, FACS, Fellow (AAOS, AO, SICOT), is a Senior Consultant and Clinical Lead, Orthopaedics Dr. Rela Institute & Medical Centre, Chennai