Osteoarthritis is a condition that affects your joints, and makes them stiff and painful. It’s sometimes called ‘wear and tear’ arthritis. Osteoarthritis most often affects the joints in your body that carry weight, for example, your knees, hips, feet and spine. However, it can also affect your fingers, the base of your thumbs, elbows and shoulders, or potentially any other joint in your body.
Osteoarthritis is sometimes confused with osteoporosis (thinning of the bones) because the names are similar. However, they are different conditions
.
About osteoarthritis:
Osteoarthritis causes the cartilage on the end of your bones to get rougher and thinner. The bone underneath thickens and grows outwards, creating growths called osteophytes that can make your joint look knobbly. The capsule around the joint also thickens and tightens. Sometimes fluid builds up and your joint can look and feel swollen.
These changes to your joints can cause pain and stiffness and make it more difficult for you to get around, or do everyday tasks. Osteoarthritis can affect people in different ways. It may get worse over a short period of time and cause a lot of damage to your joints. This can have a significant impact on your day-to-day life. Or, you may find that your condition develops slowly over many years, causing small changes to your joints that don’t get any worse. They may even ease over time.
There are many treatments and self-help measures that can ease your symptoms even though there isn’t a cure for osteoarthritis.
Osteoarthritis is the most common type of arthritis in the UK; it causes joint pain in around eight and a half million people. It’s more common over the age of 50, although it can develop in younger people too.
Symptoms of osteoarthritis
When osteoarthritis first develops, you may have some stiffness and pain in your joint. This might get worse when you move or put weight on it.
As your condition develops you may notice other symptoms. The main ones are listed below.
• A deep, aching joint pain. Depending on which of your joints is affected, you may find this pain spreads. For example, if you have osteoarthritis in your hip, you may have pain down the side or front of your thigh and into your buttock. This is called radiated pain.
• A reduction in your range of movement in the joint. This means you won’t be able to move your joint into the positions you did before, or move them as far.
• A crunching and grinding sensation and noise in your joints when you move them. This is called crepitus.
• A change in the shape of your joint, with hard bony growths and soft swelling caused by extra fluid.
• Your joint may give way when you put weight on it. This can happen because your muscles have weakened or because your joint is less stable.
There may be times when your symptoms get worse. For example, when the weather is damp or when you have been more active than usual.
If you have any of these symptoms, see your GP.
Causes of osteoarthritis
The exact reasons why you may develop osteoarthritis aren’t fully understood at present. However, certain factors may increase your risk of developing the condition. You’re more likely to develop osteoarthritis if:
• one of your parents has the condition
• you’re over 50
• you’re overweight or obese
• you have previously injured or had an infection in your joint
• you have another arthritic condition, such as rheumatoid arthritis or gout
Diagnosis of osteoarthritis
Your GP will ask about your symptoms and will ask to examine you. He or she may also ask you about your medical history.
There is no single test for osteoarthritis and an examination is often all that is needed to diagnose the condition. Your GP may look to see if you have any bony growths and swelling and any creaking in your joint. He or she might also check how well your joint moves and how stable it is.
Your GP may suggest you have an X-ray of your affected joint. An X-ray can help to show if the normal space in your joint is reduced because you have lost protective cartilage. It can also show if you have any extra bone growth around your joint or any roughening or thickening of the surface of your joint. Sometimes calcification of the cartilage can be seen on X-ray images. This is when calcium builds up in a joint, usually your knee. It’s more likely in older people who have osteoarthritis.
Treatment options for osteoarthritis:
There are a number of treatments that can help you to manage osteoarthritis and control your symptoms. However, there is no cure for the condition.
Which treatments you’re offered will depend on your personal circumstances. Your doctor will discuss these with you to help you make a decision that’s right for you. Your decision will be based on your doctor’s expert opinion and your own personal values and preferences.
Self-help
There are many things you can do to reduce the pain and stiffness in your joints, and to make day-to-day life easier. Self-help measures can help to reduce the stress on your joints and reduce the severity of your condition. Some of the main ones are listed below.
• Try to maintain a healthy weight for your height. This may mean losing excess weight because this can put more stress on your joints and make osteoarthritis worse.
• Exercise regularly and keep moving. Exercise can help to keep your joints working well.
• Pace yourself. For example, spread out any chores that need doing, rather than trying to do them all at once.
• Use a walking stick to ease any stress on your knee or hip joint.
• Wear shoes with a soft, thick, cushioned sole or use an insole. This will help to reduce any jarring.
• Massage the muscles around your joint to help ease pain.
• Use a heat pad or an ice pack to help relieve pain. Don’t put either of these directly onto your skin as they may damage it or even give you a burn. Wrap them in a towel or dishcloth first.
• Think about making changes to your car, home or workplace to ease any stress on your joints. You may be able to get help from an occupational therapist. This is a health professional who can give practical assistance to help you manage with everyday tasks and increase your independence.
• Use braces or supports to keep your joint stable and provide support. Ask your GP about these.
Treatment Options for Osteoarthritis
in the Knee
Osteoarthritis of the Knee
Non-Surgical Treatment
• Exercise and Weight Loss
• Bracing
• Medication
• Viscosupplementation
• Cortisone Injection
Surgical Treatment
• Arthroscopy, Chondroplasty
• Microfracture / Abrasion
• OATS Procedure
• Meniscus Reconstruction
• Osteotomy – Tibial & Femoral
• Unicompartmental Knee Replacement
• Total Knee Replacement
Figure 1: Non-arthritic Knee
Figure 2: Arthritic Knee
Osteoarthritis of the Knee:
Osteoarthritis is the most common cause of musculoskeletal pain and disability in the knee joint. In the knee joint, the end of the femur (thigh bone) and tibia (shin bone) are covered in smooth articulate cartilage. Between the two bones sits a second type of cartilage, called menisci, which act as cartilage shock absorber pads. Joint fluid also adds lubrication to the knee joint. Osteoarthritis (OA) starts as the lack or loss of this articulate (surface) cartilage and then progresses into involvement with the surrounding bone, tissues, and synovial fluid. In osteoarthritis, cartilage may have areas of partial thickness loss (thinning) or complete loss of surface cartilage resulting in areas of exposed bone. Isolated cartilage loss may be a result of isolated trauma or it may be a result of chronic wear and tear of the joint.
It has been estimated that 12% of Americans aged >25 years have clinical signs and symptoms of OA. Further studies have shown 80% of people older than 75 have symptoms of OA, and cadaveric studies have shown universal signs of arthritis in patients 65 and older. Studies have provided conflicting evidence regarding activities and the development of osteoarthritis. While moderate physical stress helps maintain the integrity of the surface cartilage, excessive stress may result in cartilage degradation. Risk factors for OA include age, injury, anatomic joint abnormalities, heredity, high bone mineral density, joint hypermobility, obesity, muscle weakness, and overuse or under use of the joints.
Symptoms of osteoarthritis include joint pain with activity, night pain, morning stiffness, limited motion, joint inflammation, crepitus or noise from the knee, and deformity. Below are pictures of osteoarthritis in a knee joint.
There are several options in treating osteoarthritis, both surgical and nonsurgical. All options are not always appropriate for each patient. Information gained from X-rays, MRI and knee arthroscopy all are helpful in determining an appropriate treatment plan.
Nonsurgical Treatment Options:
Exercise and Weight Loss
Nonsurgical management starts with weight loss and muscle strengthening. Each pound of weight can put up to 6 pounds worth of pressure on the knee joint during activity. Thus people of a larger size tend to develop arthritis at an earlier age and to a greater severity than their slim counterparts.
Muscle strength is also vital in combating osteoarthritis. The muscles surrounding the knee joint act as shock absorbers for the pressure that daily activities and sports place on the joint. The stronger the muscles are that surround the knee joint are, the more stress they can absorb for the knee joint. Increasing muscle strength will decrease pressure otherwise placed on the joint, thus decreasing symptoms.
Exercises that will increase quadriceps, hamstring and calf strength include ¼ squats, leg press and leg extension. These exercises should be pain free and done with limited flexion or bending of the knee, not greater than 45 degrees. In addition to these focused strengthening exercises cardiovascular exercise such as cycling, elliptical, rollerblading, and swimming will also be beneficial. Strengthening exercises should be done at least 3x/week to build muscle strength.
Bracing
Knee braces are available for treatment of medial compartmental osteoarthritis (arthritis on the inside of the knee joint). These braces work by unloading the medial (inside) portion of the knee. These braces need to be custom made and therefore can be expensive.
Medications
In addition to weight loss and strengthening, anti-inflammatory medications may also help decrease symptoms. These medications are available in both over the counter and prescription doses. Aspirin, Ibuprofen (Advil) and Naprosyn (Aleve) are all examples of over the counter anti-inflammatory medications (NSAIDs). Other prescription strength NSAIDs include Indocin, Daypro, Relafen, Celebrex, Lodine, and Mobic. Acetaminophen (Tylenol) may also be taken for OA pain but it is less effective for inflammation than other medications.
The most common side effect from NSAIDS is stomach irritation. Other potential side effects include be stomach ulceration (greatest in those with acid reflux, use corticosteroids, smokers, and those who drink alcohol), and renal damage (greatest in those older than 65, individuals with hypertension or congestive heart failure or those taking diuretics or ACE-inhibitors). Patients who are on anticoagulation therapy should use NSAIDs with caution.
The most common side effects of Tylenol are nausea, constipation and occasionally drowsiness. The most worrisome side effect from Tylenol is liver toxicity which is rare when the medication is taken as directed.
All medication use and dosages should be discussed with Dr King, Laurel or Melissa.
Nutritional Supplements
Supplements such as glucosamine sulfate and chondroitin sulfate are widely used but not regulated by the FDA. Glucosamine, an aminomonosaccharide, is a primary component of connective tissue (including cartilage). It is not know however, if taking glucosamine orally has any effect on the knee joint. Chondroitin sulfate is found in proteoglycans which contribute to the stability of cartilage. In supplementation form, chondroitin is derived from bovine and calf cartilage. Several clinical studies are in process evaluating effectiveness, efficacy, and monitoring any long term adverse effects of glucosamine and chondroitin.
Viscosupplementation
Within the knee joint synovial fluid is highly viscous which provides a friction-free environment. Hyaluronic acid (HA) which is present in our synovial fluid is also found in most body tissues. In a healthy adult, synovial fluid HA has a molecular weight of 4-5 million. As a result of this large size HA molecules entangle, forming coiled configurations which in turn provide elasticity and viscosity to synovial fluid. HA also binds to proteoglycans to stabilize the structure of the articulate cartilage. In patients with OA, the molecular weight of the HA decreases causing the synovial fluid to become less viscous thus leading to increased friction and abnormal joint movement.
Lubrication or Hylagan injections provide the joint extra lubrication and shock absorption, as well as decrease friction or rubbing within the joint which may slow the progression of osteoarthritis. However, of all the patients who receive Hylagan injections, only about 50% have symptomatic relief. One injection is given into the knee each week for three weeks and may be repeated as soon as 6 months. Up to five injections may be given, but studies have shown no difference in symptom relief after 3 or 5 injections.
Cortisone Injection
Injection of cortisone into the knee joint has been shown to be effective for ‘flares’ of arthritis symptoms, as they are a direct acting anti-inflammatory medication. However, research has also shown deterioration of articulate cartilage after repeated cortisone injections. Therefore, these injections are only used with caution in the knee joint.
Surgical Treatment Options
Chondroplasty
In addition to nonsurgical management of osteoarthritis, several surgical options exist. Surgical options include first a knee arthroscopy (scope) and chondroplasty. Chondroplasty is a smoothing of roughened articulate cartilage. The smoothing may decrease the friction inside the joint but is performed conservatively as to prevent thinning of the surface cartilage.
Abrasion / Microfracture
Abrasion arthroplasty, or micro-fracture, is appropriate for small areas of exposed bone or complete loss of cartilage. Abrasion of the area exposed bone is performed with a surgical pic which stimulates the bone to bleed allowing the bone to in response grow scar cartilage over the previously exposed area. The resulting cartilage growth and its effectiveness are variable between patients.
OATS Procedure
Osteochondral Autograft (or allograft) transplant (OATS procedure) can be performed for small to moderately large area of full thickness surface cartilage loss. These areas of full thickness cartilage loss are also referred to as grade IV chondromalacia. This procedure involves first removing a cylinder shaped dowel of bone which is lacking surface cartilage and replacing it with a dowel or cylinder of bone with intact surface or articulate cartilage. Both dowels are the same size so when they are switched there is a press fit and no hardware is needed to secure it in place.
The replacement dowel of bone with surface cartilage can either come from a non weight bearing area of bone and surface cartilage from your knee (AUTOGRAFT) or from a cadaver (ALLOGRAFT). If the lesion or area lacking surface cartilage is less than 20mm an autograft OATS may be performed, using either one or a few bone and cartilage plugs. If the lesion to be resurfaced is larger than 20mm, taking tissue from a cadaver or an allograft is needed. This tissue must be ordered and this may require a second surgery. The size of the lesion and appropriateness of either procedure is usually not known until the arthroscopy is performed.
Rehabilitation after an OATS procedure includes using crutches and partial weight bearing activity only for 3- 6 weeks, depending on the size of the lesion.
Figure 3: Autograft OATS (Arthrex Inc., 2005)
Figure 4: Allograft OATS (Arthrex Inc., 2005)
1. This first image is an Autograft OATS — before the Osteochondral plug is placed.
2. This image is after the OC plug is placed.
3. The next 5 images show a sequence of an autograft OATS procedure. The first image shows the area the bone the has the cartilage defect/loss of surface cartilage.
4. This image shows the surgeon measuring the area to be replaced.
5. This image shows the removal of the plug.
6. The next images shows the new osteochondral plug being placed.
7. The final image shows what it looks like after the plug is placed and the new surface cartilage is intact.
See also Chondromalacia Patella
+ top
Meniscus Transplant
A meniscal transplant involves implanting either a medial or lateral meniscus from a cadaver into a knee joint that is lacking greater than 50% of meniscal cartilage. X-rays or an MRI are used to measure the patient’s knee to determine the dimensions of the meniscus needing to be ordered. The wait for a meniscus may be a few weeks to several months. This procedure however, has only been found to be useful in patients with intact surface cartilage above and below the meniscus. Thousands of meniscal transplants have been done world-wide; Dr. King has done hundreds.
Rehabilitation after this procedure includes walking with crutches and a knee brace for the first 3-6 weeks with physical therapy usually starting the first or second week after surgery.
1. This image shows a thigh bone above and the shin bone below with an absent meniscus.
2. This image shows a new meniscus has been inserted, it is sutured into place while the healing takes place.
Osteotomy – Tibial and Femoral
Often patients with knee osteoarthritis may have more arthritis on either the inside (medial) or outside (lateral) of the knee, causing the alignment of the knee joint to shift towards becoming bow-legged or knock-knee. Unfortunately once alignment is no longer even activity and pressure on the knee joint can cause an acceleration of wearing of the vulnerable side of the knee as more and more weight is now transferred onto that area. An Osteotomy is a realignment procedure that unloads the vulnerable or arthritic side of the knee and puts the majority of the load of the knee joint onto the underutilized cartilage on the other side of the knee.
An Osteotomy is performed by wedging open either the tibia (shin bone) or femur (thigh bone) and adding bone graft putty to create new bone growth into the wedged area. After this procedure patients are on a home motion machine then progress to physical therapy, while using a brace and crutches for the first 4-6 weeks after surgery until the bone is well healed. This procedure is very successful in relieving symptoms and preventing or delaying an artificial knee in many patients.
Figure 5: Alignment Change with Osteotomy Arthrex Inc., 2005)
Figure 6: Femoral Varus Osteotomy (Arthrex Inc., 2005)
Figure 7: Tibial Valgus Osteotomy (Arthrex Inc., 2005)
Unicompartmental Knee Replacement
Another option for patients with osteoarthritis in one area of the knee- usually medial or lateral is an artificial resurfacing of the cartilage surface, called a unicompartmental knee replacement. This procedure is successful in relieving symptoms from osteoarthritis if the arthritis is limited to one compartment or area of the knee.
Artificial Joint Resurfacing or Total Knee Replacement:
Artificial joint resurfacing involves caping the end of the femur (thigh bone) and tibia (shin bone) with plastic and or metal pieces. These pieces are glued in place to form an artificial joint surface.
This procedure can be very effective in eliminating painful and severe OA, but it is limited by the fact that the articular components (plastic and metal) will eventually wear out and need to be replaced. Inactive people early loosening of the components can occur. For these reasons most orthopedic surgeons try to delay artificial resurfacing procedures until late in life. Biologic living joints can live 60-80 years. No artificial joint can do this.
Knee Strengthening Exercises
Exercises > Strength (Joints) > Knee Strengthening Exercises
The following knee strengthening exercises are designed to improve strength of the muscles of the knee. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should only be performed provided they do not cause or increase pain.
Begin with the basic knee strengthening exercises. Once these are too easy, they can be replaced with the intermediate knee exercises and eventually, the advanced exercises.
Knee Strengthening – Basic Exercises
To begin with, the following basic knee strengthening exercises should be performed approximately 10 times, 3 times daily. As your knee strength improves, the exercises can be progressed by gradually increasing the repetitions and strength of contraction provided they do not cause or increase pain.
Static Inner Quadriceps Contraction
Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel (figure 1). Put your fingers on your inner quadriceps (VMO – vastus medialis obliquus) to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible pain free.
Figure 1 – Static Inner Quadriceps Contraction
Quads Over Fulcrum
Begin this exercise lying on your back with a rolled towel or foam roll under your knee and your knee relaxed (figure 2). Slowly straighten your knee as far as possible tightening the front of your thigh (quadriceps). Hold for 5 seconds and repeat 10 times as hard as possible pain free.
Figure 2 – Quads Over Fulcrum
Static Hamstring Contraction
Begin this exercise in sitting with your knee bent to about 45 degrees (figure 3). Press your heel into the floor tightening the back of your thigh (hamstrings). Hold for 5 seconds and repeat 10 times as hard as possible pain free.
Figure 3 – Static Hamstring Contraction
________________________________________
Knee Strengthening – Intermediate Exercises
The following intermediate knee strengthening exercises should generally be performed 1 – 3 times per week provided they do not cause or increase pain. Ideally they should not be performed on consecutive days, to allow muscle recovery. As your knee strength improves, the exercises can be progressed by gradually increasing the repetitions, number of sets or resistance of the exercises provided they do not cause or increase pain.
Resistance Band Knee Extension in Sitting
Begin this exercise in sitting with your knee bent and a resistance band tied around your ankle as shown (figure 4). Keeping your back straight, slowly straighten your knee tightening the front of your thigh (quadriceps). Perform 3 sets of 10 repetitions provided it is pain free.
Figure 4 – Resistance Band Knee Extension in Sitting
Resistance Band Hamstring Curl
Begin this exercise lying on your stomach with a resistance band tied around your ankle as shown (figure 5). Slowly bend your knee tightening the back of your thigh (hamstrings). Perform 3 sets of 10 repetitions provided the exercise is pain free.
Figure 5 – Resistance Band Hamstring Curl
Squat with Swiss Ball
Begin this exercise in standing with your feet shoulder width apart, your feet facing forwards and a Swiss ball placed between a wall and your lower back (figure 6). Slowly perform a squat, keeping your back straight. Your knees should be in line with your middle toes and should not move forward past your toes. Perform 3 sets of 10 repetitions provided the exercise is pain free.
Figure 6 – Squat with Swiss Ball
________________________________________
More Intermediate Exercises
For more intermediate exercises designed to improve your knee strength ‘Become a Member’
Already a Member?
View the complete article – Knee Strengthening Exercises (Members Only)
________________________________________
Knee Strengthening – Advanced Exercises
For advanced exercises designed to improve your knee strength ‘Become a Member’
Already a Member?
View the complete article – Knee Strengthening Exercises (Members Only)
________________________________________
Physiotherapy Products for Knee Exercises & Rehabilitation
• Resistance Band
• Swiss Balls
• Foam Rollers
• Pilates Mats
• Massage Balls
• Wobbleboards
• Dura Discs
• Knee Braces
