Knee Joints Pain Treatment Exercise, Complications

• Glucosamine compounds –  in particular, have attracted a great deal of attention, mostly in the lay press. Possibly as a function of this publicity, osteoarthritis is the leading medical condition for which people use alternative therapies.^w6 Glucosamine and chondroitin seem to have the same benefit as placebo,^Rxand there is controversy over whether they also have structure modifying benefits.
• COX-2 inhibitors
• Glucosamine and chondroitin sulfate
• Corticosteroid injections
• Hyaluronic acid (HA)

• Viscosupplementation with hyaluronic acid (HA) – Injection into the knee with HA (similar to the main component in cartilage) has been reported to provide temporary pain relief for up to three months. Evidence to date on the use of HA has been contradictory, and recommendations regarding its use remain inconclusive[,2Rx ]Currently, the American Academy of Orthopaedic Surgeons does not recommend using hyaluronic acid for patients with symptomatic end-stage osteoarthritis (OA) of the knee. There are no existing data that any of the HA injections will cause regression of osteophytes, subchondral bone remodeling, or regeneration of cartilage and meniscus in patients with substantial, irreversible bone and cartilage damage. Further investigations are required to determine whether high-molecular-weight and cross-linked preparations of HA have superior efficacy compared with other HA preparations or other currently available treatments. In addition, studies involving long-term outcomes of efficacy, safety, and economic cost-benefit analyses are needed.Rx Because of the paucity of data supporting the effectiveness of HA injections to justify their cost, careful patient selection and decreasing the use of HA among patients with end-stage knee OA may represent a substantial cost reduction without negatively affecting the quality of health care.Rx
• Intra-articular corticosteroids – Intra-articular injections of corticosteroids have long been used to try to relieve symptoms from knee OA, but studies addressing their efficacy have been contradictory. The American Academy of Orthopaedic Surgeons guidelines for nonoperative treatment options for patients with OA of the knee does not recommend for or against the use of intra-articular corticosteroids into the knee.Rx Furthermore, a recent Cochrane systematic review concluded that clinically important benefits of one to six weeks remain unclear because of the overall quality of the studies, the heterogeneity between trials, and the presence of small-study effects.Rx
• Intra-articular hyaluronan – Though the meta-analyses reviewing the efficacy of intra-articular hyaluronan are not in complete agreement, mainly because of variation in study methods, most suggest that the effect size is relatively small and the placebo response is significant.^Rx

• Cell-based therapies – Cell-based therapies for knee OA are in development stages. A recent systematic review suggested that intra-articular cellular injections for OA and focal cartilage defects in the human knee had positive results and seemed safe. However, improvement in patient symptoms was modest and a placebo effect could not be disregarded. The overall quality of the literature was poor; therefore, accurate assessment and optimization of these therapies will require further research. Rx Most of the studies analyzed reported on the use of autologous cellular therapies. Bone marrow-derived cells were the source chosen more often, followed by adipose-derived cells and blood stem cells.
• Platelet-rich plasma – Multiple studies and systematic reviews have reported on the use of intra-articular PRP for the treatment of knee OA.Rx Initial observations support an inference that PRP appears to be safe. Although some transient pain or swelling has been reported after its use, these symptoms typically resolve within two to three days, and no long-term side effects have been reported. Use of PRP, especially a lower leukocyte concentration known as leukocyte-poor PRP, showed improved results compared with HA and placebo, showing beneficial effects of amelioration in pain and improvement in function about two months after application and lasting up to a year. Rx–Rx On the basis of the current evidence, although PRP injections have been demonstrated to more effectively reduce pain and improve overall physical function compared with control studies, the quality of evidence is lacking, and further research is required to establish the efficacy of using PRP as a treatment option.
• Glucose Amaine with  Chondroitin Sulphate – Glucosamine and chondroitin have been widely promoted as a treatment for OA. Glucosamine, an amino sugar, is thought to promote the formation and repair of cartilage. Chondroitin, a carbohydrate, is a cartilage component that is thought to promote water retention and elasticity and to inhibit the enzymes that break down cartilage. Both compounds are manufactured by the body. Glucosamine supplements are derived from shellfish shells; chondroitin supplements are generally made from cow cartilage.
• Duloxetine – This antidepressant, which was evaluated for OA for the first time in these guidelines, may help with chronic pain. However, side effects like nausea, dry mouth, fatigue, constipation, and increased sweating may keep some people from taking it. Duloxetine is appropriate for people with OA of the knee and other joints. Whether people with knee-only OA and coexisting health conditions should take it is uncertain.
• Capsaicin  – This analgesic, which is derived from chili peppers, is better than a placebo at reducing pain, but it can cause side effects such as a burning sensation or skin redness. It’s appropriate for knee-only OA in people without existing health conditions, but uncertain in people with multi-joint OA and those with health conditions.
• Opioid and narcotic analgesics – A review of 18 randomized controlled trials showed a significant reduction in pain and some improvement in physical function with the use of these strong pain relievers. However, these benefits were countered by significant side effects, including nausea, constipation, dizziness, sleepiness, and vomiting. Overall, about a quarter of patients treated with opioids—and particularly with strong drugs like oxycodone and oxymorphone—dropped out of studies because of side effects. The recommendation on both oral and patch forms of opioid pain relievers is “uncertain.”
• Corticosteroid injections  – Injecting corticosteroid compounds directly into affected joints can be useful for decreasing pain in the short term, although the effect tends to wear off after a few weeks. To maintain relief, you may need to have corticosteroid injections in the same joint every few months or use another treatment.
• Hyaluronic acid injections   – Hyaluronic acid is meant to supplement a natural substance that gives joint fluid its viscosity. Most of the studies conducted have been in patients with knee OA. Although the study outcomes differ, some do find the treatment relieves pain. Hyaluronic acid injections seem to reach their peak benefit 8 weeks after the shot is given, and the effect lasts for about 24 weeks. Side effects were minimal, including temporary pain and swelling at the injection site. Because of inconsistent study results, hyaluronic acid injections are “not appropriate” for people with OA of the hip and other joints, and “uncertain” for those with knee-only OA.
• Risedronate (Actonel)  – This bisphosphonate drug is better known for treating osteoporosis, but it may also reduce cartilage degeneration. More studies are needed to determine whether risedronate helps with symptoms, function, or OA disease progression. For now, the drug is deemed “not appropriate.”
• 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.
• Duloxetine  – Normally used as an antidepressant, this medication is also approved to treat chronic pain, including osteoarthritis pain.
• Disease-modifying anti-rheumatic drugs (DMARDs) – are used to slow the progression of rheumatoid arthritis. Drugs like methotrexate, sulfasalazine, and hydroxychloroquine are commonly prescribed. In addition, biologic DMARDs like etanercept and adalimumab may reduce the body’s overactive immune response. Because there are many different drugs today for rheumatoid arthritis, a rheumatology specialist is often required to effectively manage medications.
• Glucosamine and chondroitin sulfate – substances found naturally in joint cartilage, can be taken as dietary supplements. Although patient reports indicate that these supplements may relieve pain, there is no evidence to support the use of glucosamine and chondroitin sulfate to decrease or reverse the progression of arthritis.

• Avocado-soybean unsaponifiables – This nutritional supplement — a mixture of avocado and soybean oils — is widely used in Europe to treat knee and hip osteoarthritis. It acts as an anti-inflammatory, and some studies have shown it may slow down or even prevent joint damage.
• Alternative therapies – Many alternative forms of therapy are unproven but may be helpful to try, provided you find a qualified practitioner and keep your doctor informed of your decision. Alternative therapies to treat pain include the use of acupuncture and magnetic pulse therapy.

Strengthening Exercises

Knee extension

Straightening the knee against resistance will strengthen the quadriceps muscles at the front of the thigh. This can be achieved in a number of ways, including using ankle weights and resistance machines. One of the easiest ways involves using a resistance band

• The patient sits on a chair with one end of the band tied around their ankle and the other end around one of the chair legs.
• The band should be taut when the knee is bent at 90 degrees. The patient straightens the knee before slowly bending it and returning the foot back to the floor.
• Perform 10-15 repetitions and repeat this 2-3 times.

Knee flexion

Still using the resistance band:

• The patient lies on the floor with the band tied around one ankle and the other end attached to something sturdy, close to the floor. The band should be taught when the knee is straight
• The patient bends the knee to bring the heel towards the buttock as far as possible, and then slowly straightens the knee back again.
• Perform 10-15 repetitions and repeat this 2-3 times.

Calf raise

Calf raises are good for strengthening the Gastrocnemius muscle which is one of the two main calf muscles, but the only one which crosses the knee joint.

• The patient stands with the feet should width apart and close to a wall or chair which can be held for balance if required.
• The patient rises up on to the toes, keeping the knees straight, before slowly lowering the heels back to the floor.
• Perform 10-15 repetitions and repeat this 2-3 times.
• This exercise can be progressed by performing on one leg only.

Squats

Squats are really good exercises for strengthening all the main muscle groups of the legs and buttocks. They can start off as very shallow movements and progress until the knees reach a 90 degree angle at which point weights can be added.

• The patient stands with the feet shoulder width apart and back straight.
• The knees are then bent as if trying to sit on a chair.
• The back should remain straight and the knees should not move forwards past the toes.
• Perform 10-15 repetitions and repeat this 2-3 times.

Acupuncture – uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.

Magnetic pulse therapy – is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has yet to be proven.

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the knee is nonsurgical. Your doctor may recommend a range of treatment options.

Lifestyle modifications –Some changes in your daily life can protect your knee joint and slow the progress of arthritis.

• Minimize activities that aggravate the condition, such as climbing stairs.
• Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your knee.
• Losing weight can reduce stress on the knee joint, resulting in less pain and increased function.
• Physical therapy – Specific exercises can help increase the range of motion and flexibility, as well as help strengthen the muscles in your leg. Your doctor or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.
• Assistive devices – Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. A brace assists with stability and function and may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used for knee arthritis: An “unloader” brace shifts weight away from the affected portion of the knee, while a “support” brace helps support the entire knee load.
• Occupational therapy – An occupational therapist can help you discover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A bench in your shower could help relieve the pain of standing if you have knee osteoarthritis.
• Other remedies – Applying heat or ice, using pain-relieving ointments or creams, or wearing elastic bandages to provide support to the knee may provide some relief from pain.
• Aerobic exercise – programs may make OA patients feel better, help reduces the joint pain, and make it easier for them to perform daily tasks. Exercise programs under medical supervision should be balanced with rest and joint care.[Rx] Aerobic programs truly border both clinical (rehabilitation) and home programs. Regardless of the setting, this program type was found to be effective for reducing pain in the hip and knee.[Rx] Patients are typically recommended to exercise between 50% and 70% target heart rate for a minimum of 30 min, 3 times a week, for overall weight management, health benefits, and a reduction in pain which was noted after a 6-month program.[Rx]
• Hydrotherapy (balneotherapy) – involves the use of water in any form or at any temperature (steam, liquid, ice) for the purpose of healing. In aquatic physical therapy or hydrotherapy, exercise activities are carried out in heated pools by a variety of providers.[Rx] Hydrotherapy/balneotherapy and aquatic therapy displayed positive results when conducted for testing a subject’s strength and flexibility. The results emphasized the role of these therapies in aiding normal walking and relieving joint pain.[Rx] The sessions typically are run from 6 to 48 weeks for the duration of 60 min and are conducted in a shallow pool with water temperatures ranging from 29°C to 34°C.[Rx]

Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment. As with all surgeries, there are some risks and possible complications with different knee procedures. Your doctor will discuss the possible complications with you before your operation.

Arthroscopy – During arthroscopy, doctors use small incisions and thin instruments to diagnose and treat joint problems. Arthroscopic surgery is not often used to treat arthritis of the knee. In cases where osteoarthritis is accompanied by a degenerative meniscal tear, arthroscopic surgery may be recommended to treat the torn meniscus.

Cartilage grafting – Normal, healthy cartilage tissue may be taken from another part of the knee or from a tissue bank to fill a hole in the articular cartilage. This procedure is typically considered only for younger patients who have small areas of cartilage damage.

Synovectomy – The joint lining damaged by rheumatoid arthritis is removed to reduce pain and swelling.

Osteotomy – In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint. Knee osteotomy is used when you have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting your weight off the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in your arthritic knee.

Total or partial knee replacement (arthroplasty) – Your doctor will remove the damaged cartilage and bone, and then position new metal or plastic joint surfaces to restore the function of your knee.