Health

Management
Osteoarthritis may be treated with exercise, medications, knee injections and surgery. These techniques may be done in combination or stepwise fashion.

Once the doctor has been able to hear your history, examine your knee and review the imaging studies, a diagnosis can be made and your doctor can then discuss the treatment options with you. After that discussion and your surgeon’s recommendation, you will need to decide which course of action to take. 

Rehabilitative
Formal physical therapy for osteoarthritis focuses on creating a specific exercise program for the patient. It may include stretching, strengthening, aerobic conditioning, proprioceptive training (knowing where a joint is in space), joint protection and energy conservation techniques.

Patients with knee osteoarthritis often have difficulty with moving their knees. For people to do normal everyday activities easily, their knees need to be able to straighten out fully and bend at least 90 degrees. Flexibility training helps improve range of motion. Furthermore, stretching shortened muscles to their normal length allows them to move more efficiently and more powerfully. Slow, gentle and sustained stretching for at least 30 seconds is encouraged. Jerky motion or bouncing is to be avoided, since it can lead to increased injuries such as ligament or muscle tears. 

Strengthening is important since muscles help protect joints by controlling motion, thereby decreasing pressure on the joint. In knee osteoarthritis, the quadriceps muscles of the thigh usually require strengthening. Quadriceps are responsible for straightening the knee and are, therefore, important in controlling movement of this joint. 

Like strengthening, proprioceptive training allows for better control of joint motion, which helps with joint shock absorption. By having a better sense of where the joint is in space, one is able to move the body with more control and therefore more safely.

All of these lead to better biomechanics or movement, which promotes joint protection. Stresses to the joint are reduced while joint movement and alignment are improved. Think of it like a car whose wheels need to be properly balanced and aligned in order to decrease wear and tear and help them to last longer.
With energy conservation, the goal is to use available activity and energy as efficiently as possible in order to maximize work that can be done. Examples include taking more rest breaks and grouping tasks so that unnecessary walking is minimized.

Due to the way the hips, knees and ankles are aligned, most osteoarthritis occurs in the middle part of the knee first. In order to decrease pressure in this area and slow the progress of osteoarthritis, an unloading knee brace may be used. Similarly, a lateral wedge foot insert may be worn in the shoe. By tilting the ankle, the forces at the knee are modified so that the middle portion is unloaded. Some people have tried using knee wraps such as neoprene sleeves. It is thought that improved proprioception allows for better control over the area, thereby improving function.

Finally, walking or gait aids such as a cane or a walker may also be used to help unload the joint.  

Medical
The drug of choice for osteoarthritis is acetaminophen (Tylenol) which has been found to be as effective as Non-Steroidal Anti-Inflammatory Drugs (NSAID) (ibuprofen [Advil], naproxen [Aleve]) but usually with less side effects. If a patient has had liver problems, he may need to limit the use of acetaminophen, since the liver is responsible for clearing the body of toxins produced from this medication.

For those who do not find pain relief with acetaminophen or for those with a higher level of inflammation, NSAIDs may be useful. Kidney damage and gastrointestinal bleeding are common side effects for this group of drugs. Risk factors for a patient incurring kidney damage include having serum creatinine more than or equal to 2 (a measure of kidney function; the higher the number, the worse the kidney), patient being more than 65 years old, having high blood pressure or congestive heart failure, use of certain medications like diuretics [furosemide (Lasix)] or ACE inhibitors [lisinopril (Prinivil)]. Risk factors for gastrointestinal bleeding include age more than 65 years old, having had a stomach ulcer or upper gastrointestinal bleeding in the past, use of corticosteroids [prednisone (Deltasone)] or anticoagulants [warfarin (Coumadin)], smoking, drinking alcohol, poor general health or longer duration of NSAID use. COX II inhibitors like celecoxib or Celebrex may limit the gastrointestinal but not the kidney side effects. 

Capsaicin, a cream made from chili peppers, may provide some pain relief as well. It works by using up a chemical, substance P, which is critical in sending pain signals to the brain. When substance P is used up, the nerve has a harder time sending pain signals to the brain, so pain is decreased. Unfortunately it takes about two weeks for substance P to be depleted and the capsaicin needs to be applied to the knee four times a day for it to work.

Corticosteroid injections for knee osteoarthritis are widely used. Steroids may be helpful due to their anti-inflammatory effect. Moreover, the removal of joint fluid prior to steroid injection may be beneficial as well. By decreasing joint fluid volume, there is a decrease in pressure in the joint capsule surrounding the knee. Removal of substances that promote inflammation may help as well. Unfortunately, the effect of these injections is usually temporary. Their effect usually lasts only several weeks. A maximum of three injections per year is the commonly accepted limit.

The knee joint is bathed in synovial fluid, which acts as a natural lubricant and provides nutrition for the cells and cartilage in the area. Injections using viscosupplementation to supplement this natural fluid are another way of treating osteoarthritis of the knee. It is uncertain how viscosupplementation works. It is thought that it may decrease inflammation, allow the body to increase production of its own lubricant or directly increase the amount of lubricant cushioning the knee. There are currently two types of substances available for this procedure in the United States. These are hylan GF-20 (Synvisc) and sodium hyaluronate (Hyalgan and Supartz). Unlike corticosteroid injections, several injections of these substances are done in series for each treatment cycle. 

Surgical
Surgery for knee osteoarthritis will be discussed in a separate section.