Nonsurgical Treatment of Knee Osteoarthritis

Marc DeJong, M.D.Orthopedics and Sports Medicine

www.SpringfieldClinic.com/DoctorIsIn

What is Primary Care Sports Medicine?

• Primary care background• Family Practice• Internal Medicine• Pediatrics• Physical Medicine and Rehabilitation (Physiatrist)• Emergency Medicine

• Additional Fellowship training

• Even more testing

What is Primary Care Sports Medicine?

• Non-surgical Orthopedics

• All ages

• Procedures

– Trigger point and soft tissue injections

– Joint injections

– Casting and splinting

How did I get here?

Medical School

Internal Medicine Residency

Sports Medicine Fellowship

Moving On . . .

What is Osteoarthritis?

• Arthritis = “joint inflammation”

• 100+ different forms

• Osteoarthritis (OA) > all others combined

• Not just “old age” or “wear and tear”

What is Osteoarthritis?

• Exact cause?

• Cartilage breaks down

• Factors

– Age

– Weight

– Prior injury

– Other diseases (RA, gout)

– Genetics

– Enzyme imbalance

– Limited healing potential

What Does It Feel Like?

• Widely variable

• Pain—during or after use; after rest

• Pain with weather changes

• Swelling and stiffness

• Decreased flexibility

• Instability, locking, catching

Treatment Options

• No cure

• Combination approach is typically best

Treatment Options

• 1: Weight loss/weight control

– Single most important factor

– Statistical benefit for every 5 pounds lost

Treatment Options

• 2: Healthy eating

– Important part of weight control, overall health

– No specific diet or foods proven effective for arthritis

Treatment Options

• 3: Staying active

– Get moving

– Rest when necessary, but only when necessary

– What do you enjoy?• Walk, bike, swim, elliptical• Tai chi• Running

Treatment Options

• 4: Strengthening

– Studies show that stronger quad muscles slower rate of progression

– Not just the knee!• Core, hips, legs

Treatment Options

• 5: Physical Therapy

– Excellent level of evidence

– Safe and effective

– Improved function

– Decreased pain

– Option of water based rehab

Treatment Options

• 6: Heat

– Gentle, moist heat for comfort

– Potential use before exercise

• 7: Ice

– Short term help for pain and swelling

Treatment Options

• 8: Relaxation techniques

– Meditation

– Deep breathing

– Biofeedback training

Treatment Options

• 9: Bracing

– Neoprene sleeve

– Hinged knee brace

– Custom arthritis (unloader) brace

Treatment Options

• 10: Supplements

– Many variations; largely unproven

– Unregulated

– Glucosamine chondroiton• Exception? Dona (glucosamine)

– May opt to try for 2-3 months

Treatment Options

• 11: Medications

– Topicals• Over the counter examples: Aspercreme, Icy Hot, Ben

Gay, capsaicin• Prescription options: NSAID (e.g. Voltaren) or

compounded creams

Treatment Options

• 11: Medications

– Acetaminophen (brand name: Tylenol)• Pain reliever, not an anti-inflammatory• Proven effective with mild to moderate pain from OA• Maximum daily dose of 3000mg• Discuss with your primary care physician

Treatment Options

• 11: Medications

– NSAIDs (non-steroid anti-inflammatory drugs)• E.g.’s include ibuprofen (Advil, Motrin) and naproxen

(Aleve)• Numerous different prescription NSAIDs• Pain control and anti-inflammatory agents• Higher risk of side effects

– Tinnitus, GI ulcers and bleeding, liver and kidney

Treatment Options

• 11: Medications

– COX-2 inhibitors • Rx only• Celecoxib (Celebrex)• Vioxx removed from market 2004• Similar to NSAIDs• Likely less damaging to the stomach lining

Treatment Options

• 12: Cortisone Injections

– “Steroids”

– Can be very effective for short term pain relief

– Do not prevent progression of the arthritis

– Limited to 3-4 per year per joint

– Overexposure may further damage cartilage

Treatment Options

• 13: Hyaluronan

– Gel-like material formulated to imitate the fluid from healthy joints, act as lubricant/”shock absorber”

– Originally derived from rooster combs

– E.g.’s include Supartz, Hyalgan, Euflexxa, Synvisc

Treatment Options

• 13: Hyaluronan

– Often used in a series of 3 weekly injections

– Ultrasound may be used to ensure accuracy

– Delayed effect

– Last 6+ months

– Appear to be safe for repeated use

Treatment Options

• 14: Surgery

– Last resort?

– Role for arthroscopic debridement (“cleaning out”)• No longer!

– In appropriate setting, results are confirming

– “Prehabilitation” is important

Points to Remember

• Osteoarthritis has variable factors and symptoms

• Extensive non-surgical treatment options

– No miracles

– No single best treatment regimen

Thanks!