Knee arthritis treatment is complex and to make matters worse, there is a lot of misinformation from online sources and medical professionals. To address these issues, I’ve prepared this comprehensive summary table which details all the most common treatments for knee osteoarthritis.
I’m going to discuss which treatments offer the greatest hope for pain relief and functional improvements as well as those capable of slowing the progression of arthritis. Additionally, I will scrutinize treatments that warrant caution due to their risk of side effects. My goal is to provide you with a comprehensive understanding of knee osteoarthritis, offering you the knowledge and confidence to make choices that nurture and protect your knee health.
Knee Osteoarthritis
Osteoarthritis is the most common type of arthritis and is characterized by the progressive loss of cartilage. And in treating many people with arthritis, I’ve found that most have a limited understanding of what it is and how to manage it.
First and foremost, it’s important to point out that our understanding of what causes arthritis is evolving. Genetics and age certainly contribute, as do joint injuries, knee trauma, and prior knee surgeries. However, in the last few years, we are also learning that arthritis is as much a metabolic disease as it is a wear and tear disease.
What this means is that metabolic factors like blood sugar levels, triglycerides, cholesterol, blood pressure, and body weight all play major roles in the onset and exacerbation of arthritis. Multiple studies show that those with metabolic syndrome experience more severe pain, worse swelling, and increased stiffness. This is why taking a multimodal approach to treating arthritis is essential.
I’ve summarized all the most common treatments for knee arthritis in this table. Now I know there is a lot of information here but let’s break it down together. I like to categorize arthritis treatments into five big categories. The first three categories are treatment options that provide short term pain relief, treatment options that provide longer term pain relief, and treatment options that may slow the progression of arthritis and decrease the risk of getting knee replacement surgery.
The fourth category addresses the risk of major side effects, while the fifth considers the cost of treatment. Now to help you navigate this information, I've included timestamps allowing you to jump around to learn more about the treatments that most interest you. Additionally, I’ve put links in the video description to example devices, braces, and supplements that I talk about during this discussion.
Exercise Therapy
Ok so let’s start by talking about the three best treatments for knee osteoarthritis. First up is exercise. Clinical trials continue to show that exercise therapy is one of the most effective treatments for knee osteoarthritis. Systematic reviews and meta-analyses have found that exercise is just as effective at reducing pain and improving function when compared to medications such as ibuprofen and naproxen.
Exercise comes in two flavors. This first is aerobic exercise such as daily walking. Walking has all sorts of benefits including benefits to all cause mortality, cardiovascular disease, mental health, cognitive function, immune function, weight loss, and more. Specifically for arthritis, walking helps prevent arthritis from getting worse and those who walk every day tend to have better outcomes. Other excellent forms of low impact aerobic exercise include cycling, swimming, and elliptical training. Aim for at least 30 minutes every day of aerobic exercise.
Now the second flavor of exercise is strength training. This is an often overlooked aspect of exercise. While aerobic exercise is beneficial, it doesn’t build muscle strength in the way that resistance training does. Focusing on strengthening the entire lower extremity, especially the muscles around the knee, has been proven to significantly lessen pain and enhance function for those with knee osteoarthritis.
Muscles not only support and stabilize our joints but also act as shock absorbers. They help reduce stress on the joints and prevent arthritis from getting worse. The contrary is also true. Weaker leg muscles have been linked to worsening arthritis symptoms in addition to worse radiographic progression of arthritis. I’ve put a link to a sample knee strengthening program here if you need guidance on which exercises to do. Aim to do a strength training program targeting the lower extremities 2 to 3 times a week.
Now before we move on to the next topic, I want to address and dispel a widely held myth. There’s a prevalent belief that running or exercising contributes to the development of arthritis, but this just isn’t true. In fact, numerous studies have shown that exercise actually protects against arthritis. Other studies have found no evidence to suggest that exercise causes arthritis. For instance, a major survey among marathon runners - who, if the myth were true, would exhibit exceptionally high rates of arthritis - found no link between their running history and an increased risk of arthritis. Instead, the most significant risk factors identified were age, body mass index, previous injuries or surgeries, and family history. Exercise was not considered a risk factor.
Diet, Nutrition, and Weight Management
Now let’s transition to talking about how diet, nutrition, and weight affect arthritis. Recent research highlights the critical role that metabolic health and systemic inflammation play in osteoarthritis. Interestingly, this inflammation isn't limited to the joints alone; it involves a complex interaction between our immune system, metabolism, and other factors.
Let's start by defining "metabolic health." This involves crucial factors like blood pressure, blood sugar levels, body weight, triglycerides, and cholesterol levels. When these factors combine unfavorably, they form what is known as metabolic syndrome. Metabolic syndrome is characterized by a specific set of issues: abdominal obesity, high blood pressure, elevated blood sugar, increased triglycerides, and low levels of HDL cholesterol.
Having metabolic syndrome significantly increases the risk of developing chronic diseases such as type 2 diabetes and cardiovascular conditions, including heart attacks and strokes. Additionally, metabolic syndrome is linked to other chronic issues like kidney disease and fatty liver disease.
Clinical research has established a link between metabolic syndrome and the progression of osteoarthritis. Recent findings show that individuals with more severe metabolic syndrome experience faster deterioration of their arthritis, evidenced by increased bone spurring, more significant bone marrow lesions, and more pronounced cartilage defects.
So the question is why? Why does metabolic health impact arthritis symptoms and progression so profoundly? Let’s take body weight as an example. First, consider the direct impact of carrying extra weight and the mechanical stress it imposes on the knees. For individuals who are obese, every additional pound translates into 3 to 4 times that pressure on weight-bearing joints, such as the knees and hips. Therefore, being 20 pounds overweight means your knee joints are bearing an additional 60 to 80 pounds of pressure. This significantly accelerates the wear and tear on these joints.
Now this offers a logical reason why individuals who are overweight experience higher rates of osteoarthritis in their knees and hips. But it also raises another question: Why are these same individuals also at a high risk for osteoarthritis in non-weight-bearing joints, such as the hands and wrists? And this is where things get really interesting.
Obesity is associated with chronic inflammation throughout the body. This isn’t the same as the acute inflammation you get from an injury – rather it’s a low-grade, persistent inflammation. Fat tissue, or adipose tissue, isn’t just sitting there. It’s actually quite active and releases molecules called adipokines, which circulate in your body and promote inflammation. This inflammation can affect the joints and contribute to the development of osteoarthritis.
All of these effects are actually compounded and magnified when we start adding in other variables such as blood sugar, triglycerides, and cholesterol. For instance, this cohort study looked to examine the longitudinal relationship between blood glucose levels and knee symptoms related to arthritis. They found that higher blood glucose levels were associated with worse knee symptoms over the 1 year follow up time period. Those with type 2 diabetes have also been found to have worse osteoarthritis, even when controlling for confounding factors such as body mass index as well as weight.
The same is true for hyperlipidemia which is characterized by high triglycerides and high cholesterol. This cross sectional study found that people with higher levels of fats in the blood were associated with higher rates of knee pain and worse clinical knee osteoarthritis.
All of these findings support the hypothesis that systemic inflammation made worse by obesity and metabolic syndrome can contribute to the development and progression of osteoarthritis and is an important aspect of the multifactorial nature of arthritis.
Ok, so if all of this is true, now let’s ask the question, what happens to the body after you lose a significant amount of weight? Do symptoms related to arthritis improve after weight loss?
This study looked at what happened to people’s knee arthritis after undergoing bariatric surgery. This is also known as weight loss surgery in which some people can lose up to 50 to 80% of excess body weight.
The researchers found notable reductions in inflammatory markers, specifically C reactive protein as well as interleukin 6. In addition, weight loss resulted in increased biomarker levels related to cartilage synthesis which is a positive sign of cartilage health. There was also a significant decrease in biomarkers linked to cartilage degradation, again, a positive sign of cartilage health.
Even modest weight loss at 5% or 10% brings considerable improvements to arthritis symptoms. This study found that losing 5% of body weight yielded slight improvements in pain, self-reported disability, and quality of life for adults with obesity and knee osteoarthritis. A 10% weight reduction had a moderate to large impact on those same outcomes.
In recent years, GLP-1 agonists like Ozempic and Mounjaro have captured headlines for their profound impact on weight loss. Emerging evidence indicates that these drugs can alleviate joint pain and slow the progression of arthritis through this weight loss mechanism.
This study highlighted that weight reduction achieved through GLP-1 agonists led to better pain management and functional outcomes, decreased dependence on pain relief medications, and a reduced need for cortisone injections among individuals with knee osteoarthritis. Even more encouraging, MRI scans revealed slower progression of arthritis and a reduced likelihood of requiring surgical interventions. Best of all, long term follow up showed that these improvements were not temporary but sustained over time.
So I hope it's now evident that there's an intricate link between obesity, metabolic health, and osteoarthritis. By focusing on these broader aspects of your health, you can tackle your arthritis more effectively. Now let’s shift focus and explore some solutions. How can you manage osteoarthritis while also considering your overall metabolic health?
First and foremost, lifestyle adjustments, particularly weight loss, can significantly impact joint health by reducing mechanical stress and systemic inflammation. A key factor in this is your diet and nutrition. Limit the consumption of processed meats and fried foods. These types of foods have been associated with triggering inflammation. Additionally, try to reduce the intake of sugary foods and high glycemic index foods. Foods with lots of added sugars contribute to the production of pro-inflammatory cytokines and can exacerbate arthritis.
Instead, try to focus on eating an anti-inflammatory diet. This means filling your plate with foods that have been shown to reduce inflammation and promote joint health. Fruits and vegetables are packed with antioxidants, vitamins, and minerals that can help combat inflammation. When it comes to protein, opt for lean sources such as chicken, fish, nuts, seeds, and legumes. These alternatives provide essential nutrients without the added unhealthy fats and inflammatory properties found in processed meats. Healthy fats, such as those found in avocados, olive oil, and fatty fish like salmon, are also beneficial for managing arthritis. These fats contain omega-3 fatty acids, which have anti-inflammatory properties and can help alleviate joint pain.
Oral and Topical Medications
Now let’s move on to talking about medications and we’ll start by discussing oral and topical options. These include pain relieving medications such as acetaminophen and opiates as well as anti-inflammatory medications such as ibuprofen, naproxen, and diclofenac gel.
Starting with acetaminophen or more commonly known as Tylenol. This is generally safe to take unless you have liver disease. Since acetaminophen is metabolized by the liver, those with liver conditions may experience reduced capacity to eliminate this medication from their body. This reduced elimination can lead to the buildup of acetaminophen to potentially harmful levels.
With that said, for individuals without liver complications, acetaminophen can be an effective option for short-term pain relief. I currently recommend taking up to 1000 mg three times a day as needed for pain. Make sure that you monitor your intake to not exceed 3000 mg of acetaminophen per day.
Next, let's discuss non-steroidal anti-inflammatory drugs, commonly referred to as NSAIDs. Common medications include ibuprofen, naproxen, diclofenac, celebrex, meloxicam. These medications are highly effective for short-term pain management, especially for arthritis, thanks to their anti-inflammatory effects. However, NSAIDs have a higher risk of side effects compared to acetaminophen, potentially impacting the heart, kidneys, and stomach. They can increase the risk of heart attacks, strokes, and high blood pressure with long-term use. Consequently, those with cardiovascular conditions should be particularly cautious with NSAIDs. Long-term use should only be considered after consulting with a healthcare provider.
An alternative to oral NSAIDs is topical NSAIDs like diclofenac gel. This form of NSAID is available over-the-counter and is applied directly to the skin. The medication acts locally to reduce pain and comes with a significantly lower risk of systemic side effects.
Regarding opioid medications such as hydrocodone or oxycodone, while they are potent pain relievers, their high risk of significant side effects and potential for addiction makes them unsuitable for treating arthritis pain. I advise against using opioids in treating arthritis due to their dangerous side effect profile.
It's important to remember that oral pain medications are designed for short-term relief and do not contribute to long-term pain management or halt the progression of arthritis. They can be useful during an arthritis flare-up but should not be considered a long-term treatment strategy for arthritis.
Dietary Supplements
Now let’s discuss dietary supplements. Two of the best studied dietary supplements that can treat symptoms related to osteoarthritis include Boswellia serrata as well as Turmeric and its active component curcumin.
Starting with Boswellia serrata, this herb is derived from the Frankincense tree and boasts a long history in Ayurvedic traditional Indian medicine as well as traditional Chinese medicine. One of the most notable properties of Boswellia serrata is its powerful pain relieving and anti-inflammatory effects.
This systematic review and meta-analysis examined the effectiveness of Boswellia serrata for the treatment of osteoarthritis. The researchers found that Boswellia and its extract can reduce pain, reduce stiffness, and improve joint function when compared to controls. The results of this study were consistent with a prior 2018 study that looked at over 20 supplements commonly used to treat symptomatic osteoarthritis. Boswellia extract was among the standouts with large effect sizes on pain reduction.
The dosage of Boswellia serrata varies between using the raw resin or a concentrated extract. Most commercially available supplements feature the concentrated extract form. For symptomatic arthritis treatment, the typical recommended dose ranges between 100 mg to 250 mg daily.
It is important to note that Boswellia products are generally considered safe. In the studies conducted, there were no significant differences in adverse events and side effects between Boswellia and control groups. However, it's important to remember that herbal supplements can interact with prescription medications. Always consult your healthcare provider before starting any new supplement to ensure safety, especially concerning potential drug interactions.
The second supplement that I highly recommend for arthritis is turmeric and curcumin. Curcumin is a natural polyphenol and is the active ingredient in turmeric which is a spice heavily used in Asian cuisine. Specifically when looking at pain and inflammation, in vivo and in vitro studies have shown that curcumin has both anti-inflammatory as well as antioxidant effects.
This systematic review and meta-analysis found that curcumin significantly outperforms placebo in alleviating pain, enhancing function, and reducing stiffness in those with knee osteoarthritis. In addition, the researchers found that the effects of curcumin were just as strong as taking non steroidal anti-inflammatory drugs such as ibuprofen and naproxen, but without the associated side effects. The typical recommended dose of Turmeric curcumin is 1000 mg daily.
I also get asked a lot about type 2 collagen. Collagen is a type of protein that is naturally found in the body and is a key component of cartilage. The theory is that taking collagen supplements can help increase the body’s natural production of collagen. This in turn can help improve the strength and elasticity of the cartilage in the body and reduce arthritis related wear and tear.
The body of evidence supporting the use of collagen for treating knee osteoarthritis is not as robust as boswellia serrata and turmeric and curcumin, however that may be changing. A recent meta-analysis concluded that collagen derivatives may have a small to moderate effect on reducing pain and improving function.
The same is true for omega 3 polyunsaturated fatty acids which is commonly found in fish oil supplements. Recent studies suggest supplementation of omega 3 fatty acids can be effective in relieving pain and improving joint function in those with arthritis.
Another well studied supplement is the combination of glucosamine and chondroitin. While clinical trials show that the pairing can help reduce symptoms, the effect size is small and less than those of Boswellia as well as Turmeric.
I currently advise patients to consider taking Turmeric 1000 mg daily for at least 4 weeks. Additionally, I suggest starting with 100 mg of Boswellia serrata extract daily, with the option to increase the dose to 250 mg daily if necessary. Taking Turmeric and Boswellia together is generally safe, but it's important to consult your healthcare provider to ensure these supplements are suitable for your specific health situation.
The last very important thing that I want to say is that dietary supplements are not regulated by the FDA and the industry is known for false advertising and inaccurate ingredients. There are countless studies that warn people that supplement manufacturers often fail to comply with basic manufacturing standards. This is despite putting on their labels that their supplements are professional grade and third party tested.
For example, this recent study found that almost 90% of dietary supplement labels did not accurately declare the ingredients found in their products. Worse yet, 12% of products contained at least 1 FDA prohibited ingredient. So it’s very important that you do your own research when it comes to purchasing dietary supplements.
I typically recommend my patients look for NSF or USP certified supplements. Both of these are third party certifications which mean they independently assess products without being affiliated with the companies that produce them. Not only do they certify that what’s on the label is in the bottle, they also do a toxicology review to certify product formulation. Additionally, they perform contaminant review to ensure the product contains no undeclared ingredients or unacceptable levels of contaminants.
For those who are interested, I’ve put links to some NSF and USP certified supplements in the video description. Hopefully this means they are more reliable, but just keep in mind that these links are not endorsements and I can’t guarantee their effectiveness.
Red Light Therapy & Photobiomodulation
Now let’s talk about a newer type of treatment that has been gaining a lot of recent attention. Photobiomodulation, also known as light therapy, is gaining traction as a treatment option for chronic pain, with red light therapy and low-level laser therapy being used for conditions such as osteoarthritis, tendonitis, and neck and back pain.
Photobiomodulation uses various wavelengths of light to stimulate cellular responses. When cells absorb light photons, they enhance cell metabolism and trigger processes that lead to benefits like increased cell growth, anti-inflammatory effects, and the formation of new blood vessels. These cellular-level changes have been shown to significantly improve patient health outcomes.
A systematic review and meta-analysis examining knee osteoarthritis found that low-level laser therapy was more effective than a placebo in reducing pain and enhancing function, with the benefits growing over time. This indicates that laser therapy can offer immediate pain relief as well as sustained improvements in managing pain.
However, there's ongoing debate regarding the optimal frequencies and protocols for low-level laser therapy. Research indicates that its effectiveness is highly dose-dependent, and deviations from established dosing protocols can influence outcomes. This inconsistency is a key reason why some professional guidelines remain cautious about endorsing the use of red light therapy for osteoarthritis.
Meanwhile, studies using home LED devices, which are more affordable and convenient for personal use, have shown promising results in improving symptoms, presenting a cost-effective and accessible option for treatment. Should additional clinical trials further validate the benefits of red light therapy, it could become a more commonly recommended treatment option.
Based on feedback from my patients who have tried it, around half have reported positive results, while the other half observed minimal change. This contrasts sharply with clinical trial results, where most participants experienced symptom improvement. However, this difference doesn't necessarily mean the treatment is ineffective. The variation in outcomes is likely due to the different methods and protocols used by various practitioners, as well as the use of home devices, which may not always deliver the optimal therapeutic effects.
I’ve put links in the video description of higher quality red light therapy devices that hopefully will deliver better results. But again please remember, this is not an endorsement of the product, rather, it’s a starting point for your research into these devices.
Cortisone Injections
Now let’s talk about one of the most common treatments for arthritis, and that’s injections. Injection therapy can play an important role in the management of knee osteoarthritis. The most frequently administered injections are corticosteroids and viscosupplementation. However, recent studies are exploring the effectiveness of orthobiologics, such as platelet-rich plasma and stem cell therapy.
Let’s first start with cortisone shots. For years, doctors have recommended cortisone shots as a way to alleviate pain and symptoms associated with arthritis. Corticosteroids have strong anti-inflammatory properties which can help reduce inflammation and decrease pain. However, recent studies have called into question their effectiveness.
For example, this recent systematic review and meta-analysis concludes that intra-articular corticosteroid injections offer pain relief only at the short term with benefits losing clinical relevance after about 6 weeks. What’s worse is that other studies are shining light on potential serious side effects of cortisone injections.
Corticosteroids have been found to be chondrotoxic, meaning they weaken and damage healthy cartilage. Remember, arthritis by definition is the gradual wear and tear and loss of articular cartilage. So while cortisone can provide temporary relief and alleviate pain and symptoms, they result in further cartilage loss and eventually worse arthritis.
In fact, that’s exactly what this clinical trial showed. The results showed that among patients with symptomatic knee osteoarthritis, intra-articular cortisone injections, when compared with saline placebo injections, led to greater cartilage loss without any significant difference in knee pain relief.
To make matters worse, recent studies have unveiled a concerning association between cortisone injections and rapidly destructive joint disease. This is characterized by progressive joint space narrowing, osteolysis, and collapse of the joint architecture. One study found a dose response association between intra-articular hip cortisone injections and rapidly destructive hip disease. Higher dose injections as well as multiple injections significantly increased the risk. Additionally, other studies have found that each cortisone injection increases the absolute risk of undergoing knee replacement surgery by 9.4%, compared to those who did not receive such injections.
Of course, it is important to note that the associations mentioned do not establish causation. Some argue that individuals with more severe knee arthritis are more likely to receive additional cortisone shots, and were destined to get worse arthritis to begin with. This is a valid perspective.
However, what sets cortisone shots apart is the lack of similar effects observed with other common treatments for knee osteoarthritis. In fact, quite the opposite has been found. Several studies indicate that both platelet-rich plasma injections as well as hyaluronic acid injections have shown a potential to decrease the risk of requiring knee replacement surgery. The contrasting outcomes between cortisone shots and alternative treatments strongly support the notion that cortisone injections may indeed be causing more long term damage.
So I think it’s evident that corticosteroid injections carry significant and real side effects and all of this highlights the need for doctors to exercise greater caution when administering them. But I also want to be very clear. I’m not saying there still isn’t a use for cortisone injections. In my opinion, one or possibly two cortisone injections in a specific body part is probably safe.
For example, I still recommend corticosteroid injections in very specific situations. Consider a situation where a patient is suffering an arthritis flare-up but has a vacation planned with friends and family. In these cases, a cortisone injection can be a sensible option, as it seeks to offer quick and effective pain relief, enabling the patient to enjoy their trip. However, upon their return, I recommend transitioning to alternative injection therapies. These alternatives may carry a lower risk of side effects and have the potential to offer benefits over a longer term.
Hyaluronic Acid Injections
So now let’s explore some alternative treatments, starting with hyaluronic acid injections. These are also known as gel shots, HA injections, or viscosupplementation. So first, what exactly is hyaluronic acid?
HA is a naturally occurring substance found in the synovial fluid of our joints. It plays a key role in lubricating and cushioning the joints. When injected, hyaluronic acid has anti-inflammatory properties as well as pain relieving properties. The goal of HA therapy is to try to augment and restore the normal viscosity and elasticity of the synovial fluid which can then help improve joint mobility and reduce pain.
Now I want to point out that there is a lot of controversy surrounding the effectiveness of hyaluronic acid injections. For example, in 2013, the American Academy of Orthopedic surgery put out a clinical practice guideline that states “Intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee.” In 2019, the American College of Rheumatology put out their practice guideline that stated “Intra-articular hyaluronic acid injections are conditionally recommended against in patients with knee joint osteoarthritis.”
This is in contrast to the 2015 American Medical Society for Sports Medicine consensus statement which “recommends viscosupplementation injections for knee osteoarthritis in those patients above the age of 60 based on HIGH quality evidence demonstrating benefit.”
So when we have multiple medical and surgical organizations with conflicting recommendations, we want to examine the key factors why. I believe one of the biggest reasons for the variability in effectiveness of these injections lies in the method of administration.
Most orthopedists and rheumatologists perform injections using a landmark based technique. This means they palpate for anatomical landmarks and then do their best in delivering the medication into the knee joint. Sports medicine physicians are trained in ultrasound guided injections which has been shown to improve outcomes.
To illustrate my point, here is a comparison of accuracy for common injections using ultrasound guided and landmark based techniques. Landmark based accuracies often range in the low to mid 60’s. Accuracy with ultrasound guidance is almost always guaranteed.
Body Area | Ultrasound Guided Accuracy | Landmark Based Accuracy |
Glenohumeral joint | 92% | 72% |
Acromioclavicular joint | 90-100% | 17-72% |
Biceps tendon | 87% | 27% |
Elbow joint | 91% | 64% |
Hands and wrist joints | 94-100% | 59-82% |
Hip joint | 97-100% | 67-78% |
Knee joint | 96-100% | 55-100% |
Foot and ankle joints | 100% | 58-100% |
This study looked at outcomes when comparing landmark based hyaluronic acid injections to ultrasound guided injections. They found that significantly fewer patients in the ultrasound guided group went on to need knee replacement surgery when compared to the landmark based group. This difference was even more pronounced among obese patients. The reason for this is because landmark based injections are much more difficult in those with excess soft tissue.
The authors of the study conclude that we need to rethink viscosupplementation and that patients who received ultrasound guided knee hyaluronic acid injections were significantly less likely to undergo subsequent knee arthroplasty than patients receiving landmark based hyaluronic acid injections.
Lastly, when it comes to cost, hyaluronic acid injections are covered by most private insurance plans as well as by Medicare. It's important to note that while hyaluronic acid injections are covered for knee arthritis, they're often NOT covered for arthritis in other joints, such as the hips, ankles, and shoulders. If your insurance covers hyaluronic acid, it does make sense to try it as it can be an effective way to decrease pain and improve function. Just make sure your doctor administers it under ultrasound guidance.
Stem Cell Injections
Now I’d like to move on to the field of orthobiologics and regenerative medicine and we’ll first talk about stem cells. Stem cell therapies are a cutting-edge treatment and offer high hopes for those suffering from osteoarthritis. However, while there has been substantial media coverage and marketing efforts surrounding stem cell therapies, they often highlight anecdotal success stories. And while personal stories can be very compelling, they can create a perception of effectiveness that may not be fully supported by clinical evidence.
So let’s briefly explore the three main types of stem cells used in osteoarthritis treatments. First, there’s Bone Marrow Aspirate Concentrate, or BMAC for short. BMAC is obtained from bone marrow and is usually harvested from the patient’s iliac crest in the pelvic bone.
Next we have adipose stromal vascular fraction also known as SVF. SVF is derived from fat tissue and is harvested through liposuction. Last, there are stem cells from umbilical cord which are ethically sourced and processed for clinical use.
Each stem cell treatment, whether it's BMAC, SVF, or umbilical cord-derived, shares a common goal. They utilize mesenchymal stem cells and growth factors to potentially repair and regenerate damaged tissues like bone, cartilage, and connective tissue. In addition, these therapies also aim to reduce pain and inflammation through their anti-inflammatory and immunomodulatory effects.
So that’s all in theory, but what does the actual clinical evidence indicate? While numerous case reports and some smaller studies suggest positive outcomes with stem cell therapies, the overall evidence remains inconclusive. That’s why the results from this large randomized controlled trial were particularly significant.
The study investigated the three types of stem cells, again that’s BMAC, SVF, and umbilical cord tissue. The researchers compared each of these three stem cell injections to corticosteroid injections and reported outcomes at 1 year.
The results showed that there was no difference in pain scores between any of the stem cell therapies when compared to cortisone injections. In addition, no treatment groups saw any notable improvement in MRI scores. This suggests that none of the stem cell treatments helped repair or regenerate anything within an arthritic knee.
Now I want to reflect on these findings and emphasize a couple key points. First, this was a very well conducted study with a large sample size of over 400 patients. This is significantly more than the 20 to 30 patients in other clinical trials and therefore lends greater reliability to its findings.
Second, the study questions the effectiveness of stem cell treatments compared to corticosteroid injections for knee osteoarthritis. This raises an important question: is it worth paying thousands of dollars for a treatment that is not outright superior to less expensive alternatives?
Some critics would argue that a one-year study may not be sufficient to evaluate the long-term benefits or structural improvements that stem cell treatments could provide. However, it's important to note that individuals considering stem cell therapy often seek immediate results and may be reluctant to invest a significant amount of money in a treatment that requires several years to potentially show benefits.
For all these reasons, I currently do NOT recommend stem cell treatments for the treatment of osteoarthritis. This decision is based on the mixed results from recent clinical trials, many of which show little to no benefit from these treatments. Furthermore, the high cost of stem cell procedures presents a substantial financial risk, especially considering the uncertainty of their effectiveness.
Platelet Rich Plasma Injections
Ok so what’s a better alternative to cortisone, hyaluronic acid, and stem cells? I recommend considering platelet rich plasma injections. PRP has been proven highly effective in treating knee osteoarthritis and is considerably more affordable than stem cell treatments.
Platelet rich plasma injections also known as PRP are a cutting edge treatment that utilizes the healing properties of your own cells. The procedure involves a simple blood draw and then separating the blood into various components using a centrifuge. We then take the layer that has all the platelets and growth factors and then inject that into an injured area. PRP treatments have been shown to be incredibly effective in treating a variety of conditions including tendons, muscles, and joints.
One of the best studied indications for PRP injections is knee osteoarthritis and the body of evidence supporting its use continues to grow. A recent study analyzed 35 randomized controlled trials with a total of over 3,100 participants with knee osteoarthritis. This comprehensive study evaluated the effectiveness of various treatments including corticosteroids, platelet rich plasma, hyaluronic acid, and placebo.
The results showed that PRP injections were the most successful treatments in improving function and reducing pain after 3, 6, and 12 months of follow up. Even better, there were no differences in treatment related side effects or adverse events in any group when compared to placebo.
So why are your platelets so effective at reducing pain and improving symptoms? Well, our platelets are responsible for tissue healing, tissue remodeling, tissue proliferation, and most importantly, in controlling pain and inflammation. And so what we’re doing with a PRP injection is using your own body’s capacity to control pain and to control inflammation, taking it out, concentrating it, and then injecting it under ultrasound guidance back into an area that’s been irritated or injured.
And it turns out that the cellular mechanisms activated by PRP injections are way more effective than any other medication we can inject into your knee for treatment. But it gets even better because PRP does more than just improve symptoms. One of the most compelling reasons to pursue PRP is that it may also slow down the progression of arthritis. This was demonstrated in a randomized controlled trial involving 610 patients which compared the effects of PRP injections to saline placebo injections in treating symptomatic knee osteoarthritis.
The study performed MRI scans at baseline and then again at 5 years post treatment. And the results showed that PRP injections led to an almost 50% reduction in the progression of arthritis when compared to the saline placebo. So how is this even possible? Previously, the only treatments that have been shown to slow the progression of arthritis were weight loss, diet, and exercise. That’s it. So how could PRP help slow down the progression of arthritis?
Well remember, osteoarthritis is a chronic progressive inflammatory disease that causes breakdown of cartilage. Low grade inflammation damages healthy cartilage which worsens arthritis. And what does PRP do? PRP introduces a huge number of platelets and growth factors that can change the inflammatory environment inside a joint with arthritis.
The researchers from the study analyzed the synovial fluid in the knees of patients who got PRP and those who got placebo. The placebo group had no changes to the level of inflammation in their knees. However, the PRP group had a significant decrease in inflammatory markers in their knees at 6 months post injection. This drop in inflammation helps to keep healthy cartilage intact and slows the progression of arthritis.
All of this compelling evidence from clinical trials is further reinforced by leading medical organizations. Both the American Academy of Orthopedic Surgeons and the American Medical Society for Sports Medicine have acknowledged the effectiveness of PRP. They’ve released summaries and consensus statements highlighting PRP’s significant benefits in reducing pain and enhancing joint function in knee osteoarthritis.
A European society even put out a consensus statement that said “according to the results from this consensus group, given the large body of existing literature and expert opinions, PRP was regarded as a valid treatment option for knee osteoarthritis and as a possible first-line injectable treatment option for nonoperative management of knee osteoarthritis.”
The one downside of platelet rich plasma injections is that they are currently not covered by insurance. And according to this study published in early 2020, the mean cost of a PRP injection was $707 with a rather large standard deviation of $388. Hopefully as more and more clinical trials continue to support the use of PRP injections, insurances will start to cover this novel treatment.
As it currently stands, I recommend all my patients with knee osteoarthritis to consider PRP injections in addition to exercise, diet, and weight management. Hyaluronic acid is also an excellent option especially if it is administered under ultrasound guidance and if covered by insurance. I currently do not recommend the routine use of corticosteroid injections, nor do I recommend the use of stem cell injections.
Genicular Nerve Block
The next treatment I want to discuss is a genicular nerve block. This treatment provides significant relief by targeting the genicular nerves responsible for transmitting knee pain to the brain. This procedure involves injecting a local anesthetic near these nerves. The beauty of this procedure is that even though the local anesthetic’s immediate effect dissipates after a few hours, patients often experience sustained pain relief extending for several months.
There are three genicular nerves that are usually targeted at the time of the procedure. These include the superolateral genicular nerve, the superomedial genicular nerve, and the inferomedial genicular nerve. These injections are done in the office setting with ultrasound guidance and are extremely safe with very low risk of side effects or complications.
This randomized controlled trial compared genicular nerve blocks to placebo for those suffering from knee osteoarthritis. The findings revealed that participants receiving the nerve block experienced significantly greater improvements in pain and functional scores compared to those who received the placebo. However, it was noted that these beneficial effects gradually decreased over the three-month duration of the study.
And how do genicular nerve blocks compare to other treatments such as physical therapy? This study randomized over 100 patients to receive either a genicular nerve block or 10 sessions of physical therapy. After three months, both groups displayed similar improvements in pain scores.
However, by the 12 week mark, those in the genicular nerve block group demonstrated a more significant increase in walking distance. These findings indicate that while both treatments are effective in reducing pain and improving function, genicular nerve blocks may provide superior long-term benefits in terms of physical capacity for individuals with knee osteoarthritis.
Now let’s compare the nerve block to cortisone injections. This study compared a single cortisone injection to a cortisone injection plus a genicular nerve block. While participants in both groups experienced notable improvements, those who received both the cortisone injection and the genicular nerve block showed more substantial improvements across various measures. These included pain levels, functional status, and overall quality of life. The study highlights the added effectiveness of incorporating genicular nerve blocks alongside cortisone injections.
Lastly, safety is really important when we talk about medical interventions. This systematic review not only found that genicular nerve blocks are effective in reducing pain and enhancing functional abilities, but that there were no adverse effects associated with the procedure. They report that none of the nine included studies raised any safety concerns.
Ok, so after evaluating the data comparing genicular nerve blocks to other treatments like physical therapy and cortisone injections, I’d like to share my perspective on how these blocks can be integrated into a broader and more effective strategy for managing knee osteoarthritis.
Firstly, genicular nerve blocks are a very safe procedure. The majority of the studies we’ve reviewed use local anesthetics like lidocaine, which are known for their safety and minimal side effects. This makes me much more confident in recommending this procedure to my patients.
Secondly, the primary benefit of genicular nerve blocks is seen in the initial 1 to 2 months, where they significantly improve pain and function. However, it’s important to note that most studies indicate a slow and gradual return to baseline pain and function levels after about 2 to 3 months.
That’s why genicular nerve blocks are best combined with physical therapy and exercise therapy. Remember, a key aspect of treating knee osteoarthritis is both aerobic exercise and muscle strengthening exercise. And the unfortunate reality is that many people are stuck in a catch 22. They want to start exercising again but they can’t because the pain is so severe. And while you can try Advil or Aleve or Tylenol or even cortisone injections, sometimes those just don’t work well enough.
This is where genicular nerve blocks can really be a game changer. They serve as an adjunctive treatment that can provide substantial short term pain relief which in turn enables people to engage in exercise therapy. Exercise therapy is not only one of the best long-term pain management strategies but also plays a crucial role in slowing the progression of arthritis. This is true for those with mild arthritis and even severe bone on bone arthritis.
The one last thing to consider is insurance coverage. Procedures like genicular nerve blocks may be covered by Medicare and private insurances under specific conditions, though it’s worth noting that many PPO plans require prior authorization, which can complicate the process. You’ll want to find out from your specific insurance plan if genicular nerve blocks are a covered benefit.
Ok so with all this in mind, I do recommend genicular nerve blocks, but specifically for patients experiencing severe pain where conventional treatments have been ineffective. It’s crucial to recognize that these nerve blocks are not a cure-all solution, but rather an adjunctive treatment. They are particularly valuable for patients who are not suitable for knee surgery, those who prefer to delay surgery, or those who haven’t achieved sufficient relief from other pain management methods.
Trigger Point Injections
The last injection option is trigger point injections around the knee. Trigger points are hyperirritable bands of knotted muscle tissue and form as a result of underlying osteoarthritis. These muscle knots restrict range of motion and contribute significantly to functional limitations and stiffness. One of the primary reasons exercise therapy can be so effective in those with knee osteoarthritis is that they address and help treat underlying trigger points in the surrounding musculature.
What many physicians don’t realize and what many people don’t understand is that muscle problems contribute a significant amount of pain to those who suffer from symptomatic knee osteoarthritis. This study found that the prevalence of myofascial trigger points in the muscles around the knee was up to 50% in patients with mild to moderate symptomatic knee osteoarthritis. Moreover, this study found that those with moderate degree of knee osteoarthritis had significantly more myofascial trigger points in their muscles when compared to asymptomatic age matched subjects.
So there is pretty good literature data that people with knee arthritis have myofascial trigger points in the muscles around their knee, but what are the outcomes when we start to treat these muscles? This study looked to answer that question. They enrolled people with knee osteoarthritis who were waiting for a total knee arthroplasty also known as a joint replacement surgery. The authors wanted to know if these patients would get pain relief if the muscles around the knees were treated with trigger point injections.
First and foremost, the authors report that myofascial trigger points were identified in all patients enrolled in the study. 100% of them. This does make sense because all of these patients have severe arthritis and are waiting for a joint replacement surgery. The authors then performed trigger point injections to treat the muscles. They found that by only treating the muscles, the patients experienced significantly reduced pain intensity, pain interference, and improved mobility.
The most commonly affected muscles were the medial head of the gastrocnemius followed by the vastus medialis oblique. They report that there was an acute reduction in pain and notable improvement in function immediately following the intervention and that the results persisted over an 8 week course of investigation.
The authors go on to conclude that 92% of patients enrolled in the study experienced significant pain relief with trigger point injections, indicating that a significant proportion of osteoarthritis knee pain was myofascial in origin. This means that a huge proportion of the pain that people experienced from knee osteoarthritis came from the muscle, not necessarily the joint.
This next study found similar results. The authors looked at if dry needling would help reduce pain in patients with mild to moderate symptomatic knee osteoarthritis. They found that the application of one session of dry needling in the quadriceps and gastrocnemius muscles led to significant decreases in pain scores over the 1 month period of investigation.
Better yet, trigger point injections are covered under insurance. The one downside of this procedure is that it is more painful when compared to the other injections that go into the knee joint. People who do not tolerate needles or medical interventions may not be able to endure the trigger point needling required to break up all the muscle knots.
Thankfully, there are other options you can try to address and treat the trigger points. The first is heat. Heat therapy is much more effective than ice when it comes to myofascial pain. Applying heat helps increase blood flow to the muscle. This allows the muscles to loosen up and decrease tightness of the knee. This can help tremendously with knee stiffness. Many people with knee arthritis actually discover heat therapy on their own as they find that when the weather gets cold, their pain gets worse. Applying heat is simple and can be incredibly beneficial. You want to make sure you cover the entirety of the calf, the inner thigh, and the outer thigh muscles. This is best done with a larger heating pad.
The second option is acupressure therapy. These come in many forms such as massage guns, soft tissue massages, and foam rollers. All of these are designed to help relieve muscle tension and improve blood flow. I’ve found foam rolling to be by far the most effective in treating trigger points in the leg. It’s much more effective than even the most expensive massage guns. Now with that said, figuring out a comfortable position to foam roll can be tricky, so I encourage you to google how to foam roll each muscle group. The most commonly affected muscles involving knee osteoarthritis are the vastus medialis oblique, the vastus lateralis, the hamstrings, and the medial and lateral heads of the gastrocnemius.
Knee Braces
Now let’s move on to discussing knee braces. Knee bracing is advertised as a nonsurgical treatment option for individuals with symptomatic knee osteoarthritis. Studies continue to show mixed results, but in general, the existing evidence suggests that knee braces and supportive sleeves likely provide some benefits.
Knee braces provide support and stability to the joint, helping to alleviate pressure and distribute weight more evenly. This can lead to not only a reduction in pain and discomfort, but also improved functional performance. This can be particularly helpful for people with knee osteoarthritis who struggle with mobility and daily activities.
There are three main types of braces that are available to those with knee osteoarthritis. These include neoprene knee sleeves, hinged knee braces, and unloader braces.
Neoprene knee sleeves have a variety of benefits. They provide gentle compression which can help reduce swelling and inflammation in the knee joint. This can lead to decreased pain and increased range of motion. In addition, they can add some support to the knee which can help prevent injury or further damage. Knee sleeves are much less intrusive when compared to the other options and are much more versatile. They can be worn during a variety of physical activities including walking, running, cycling, weight lifting, and more.
Hinged knee braces have metal or plastic hinges on the sides of the brace that help to limit side to side movement of the knee. These provide more support than neoprene knee sleeves and are particularly useful in those who have instability of the knee. Hinged knee braces can potentially help correct alignment issues as well as reduce pain and improve function.
Knee unloader braces are designed to reduce pressure on a specific area of the knee joint and are commonly used to treat knee osteoarthritis. Knee unloader braces work by shifting the weight bearing load away from the affected area of the knee joint. They are typically designed with a hinge on one side of the brace that helps to apply a corrective force to the knee joint. This then reduces pain and improves function. Unloader braces can be modified and customized to the individual to provide comfort and support to each person’s knee.
This study looked at the efficacy of unloader braces when compared to placebo. The results showed that unloader braces led to better pain reduction throughout the day, as well as during physical activity at the one-year follow-up. However, it's worth noting that patients initially experienced worsened symptoms during the first six weeks of using the brace, indicating a significant adjustment period. Interestingly, no significant differences were found between the unloader and placebo braces at 12 and 24 weeks, with the benefits only being observed at the one-year mark.
The big problem with this study was that they had an incredibly high patient drop out rate of 44%. The primary reasons for this were mechanical issues related to the brace, including problems while working, sliding off, rubbing, feeling unstable, and being cumbersome. Notably, these findings are consistent with data from other studies.
For instance, this study found that only about 25% of patients continued to use an unloader brace regularly more than one year after fitting. The most common reasons for discontinuation were ill-fitting and uncomfortable braces, followed by inadequate symptom improvement. Other common reasons included skin irritation or swelling, difficulty wearing the brace with clothes for daily activities, and the brace being too heavy and bulky, making it difficult to put on and take off.
So this is a perfect example that although clinical trials can demonstrate the efficacy of an intervention or treatment, real-world data is more crucial. In my experience, many patients have found unloader braces to be inconvenient and counterproductive.
Ok so what about the other types of braces. Hinged knee braces and neoprene knee sleeves are more convenient and less intrusive for daily activities. Some small studies have shown that neoprene knee sleeves can help with gait and balance in people with knee osteoarthritis.
For example, this study compared pain and functional tests in people with knee osteoarthritis with and without a knee brace. They found that a simple elastic knee sleeve was highly effective at reducing pain and improving functional metrics.
Other small studies have looked at hinged knee braces with similar results. They can help with pain and function, although not to the extent that unloader braces can. However, a major limitation of these functional studies is that they are usually conducted in a controlled environment, where patients can withstand the bulkiness and weight of the brace to perform a few functional tests. These tests may show that unloader braces are effective, but when patients bring them home for everyday use, the bulky brace can become more of a hindrance than a help.
Alright so what do I recommend to my patients with knee arthritis? I actually DON’T recommend the unloader brace. In my experience, as well as based on real-world studies, unloader braces are often too cumbersome and actually interfere with quality of life. Additionally, they can be costly if not covered by insurance.
Instead, hinged knee braces are a reasonable middle ground and can be beneficial if you have knee instability or feel like your knee is giving out. It's important to note that knee braces, especially hinged knee braces and unloader braces, should not be worn 24/7 unless specifically instructed by a healthcare provider. Prolonged immobilization can be counterproductive, resulting in significant muscle atrophy.
Interestingly, some studies suggest a neoprene knee sleeve may be just as good for instability issues. For instance, this study compared a neoprene knee sleeve to a hinged knee brace for patellar dislocations. The findings showed no significant differences in dislocations, but the more restrictive hinged knee brace led to more quadriceps muscle atrophy, less range of motion, and worse functional outcomes at 6 months.
Personally, I am a fan of neoprene knee sleeves and often recommend them to my patients. They can be helpful for proprioception and provide a sense of stability, particularly during exercise and physical activity. Knee sleeves are also quite affordable and practical, making them easy to use. In addition, they can be useful for those experiencing acute osteoarthritis flare-ups, as they can reduce pain during daily activities. I’ve put links to sample knee braces in the video description that you can use as a reference point to start your research into these products if you are interested.
Arthroscopic Surgery
Last but not least, let’s discuss surgical options. There are two types of surgeries for a degenerative knee, one is an arthroscopic surgery where surgeons can use minimally invasive techniques to clean up the knee. The other is a knee replacement surgery.
Let’s first discuss the clean up surgery which is an arthroscopic partial meniscectomy and debridement surgery. Over the last decade, this has become one of the most commonly performed orthopedic surgeries in the United States. But recent clinical trial evidence has shown that arthroscopic surgery should only be performed after an extensive trial of non surgical management has failed, and even then, surgery may not result in better outcomes.
For example, there are now numerous clinical trials that compare arthroscopic surgery to physical therapy and the 5 year outcomes show that there is no difference between getting surgery and continuing with exercise therapy. Systematic reviews and meta-analyses of these trials conclude that exercise therapy results in a lower risk of knee osteoarthritis progression while also having comparable effects on pain and knee function.
More alarmingly is the data comparing arthroscopic surgery to a sham placebo surgery. First and foremost, there was no difference in patient outcomes at 1 year, 2 years, and 5 years post surgery. This means that arthroscopic surgery offered no clinical benefit when compared to a placebo surgery. What’s worse is that the researchers found that arthroscopic surgery was associated with an increased risk of progressive arthritis when compared to a placebo surgery.
In contrast, head to head trials comparing arthroscopic surgery to platelet rich plasma injections for the treatment of knee osteoarthritis show that PRP injections resulted in greater reductions to pain and functional improvements. So for all the above reasons, I do not recommend arthroscopic surgery for the treatment of knee osteoarthritis nor for the treatment of degenerative meniscus tears.
Knee Replacement Surgery
And what about a knee replacement surgery? This surgery can be a saving grace for many people suffering from osteoarthritis. And while most people see tremendous benefits, this is not true of everyone. A recent study reported that a staggering 1 in 4 people who underwent knee replacement surgery did NOT have their expectations met and were NOT fully satisfied with surgery.
The authors reported data from 352 patients who all underwent total knee arthroplasty. Patients were given a set of outcome measures as well as a questionnaire regarding their expectations before undergoing surgery.
The questionnaire consisted of 31 items reflecting symptoms, physical function, physical activity, quality of life, coping strategies, and activities of daily life. Patients were asked to rate the personal importance of these items in terms of a successful surgery, with possible answers being mandatory, desirable, or not important.
The results of the questionnaire showed that patients had very high expectations going into a knee replacement surgery. Six expectations were rated as mandatory by over 90% of patients. These include knee pain, quality of life, physical function, implant longevity, walking distance, and range of motion of the knee.
Another 11 expectations were rated as mandatory by at least 75% of patients. These include climbing stairs, mobility, knee stability, physical activities, physical endurance, muscle strength of the leg, general health status, longer standing, daily activities, preventing secondary impairments, and participation in social life. The study also found that patients rated knee-related and general health-related aspects as equally important.
The first thing to point out here is that patients have very high expectations going into a knee replacement surgery. 17 of the 31 expectations were marked as mandatory by over three quarters of patients. But even despite these high expectations, the authors report that at the one year follow-up, fulfillment of expectations was better than expected in 40% of patients, exactly as expected in 34% of patients, and lower than expected in 26% of patients.
So even though patients went into surgery with high expectations, 75% of them had their expectations met or even exceeded. This is important to point out because knee replacement surgery can be an incredibly effective procedure for many people with advanced arthritis.
But it doesn’t seem like that’s true for everyone. So now let’s look at the 26% of people who did not have their expectations met. We first start with complications. Of the 352 patients, 23 patients or about 7% of people had to go back to the operating room. This included washouts for infection, fractures, tendon rupture, and irrigation of hematomas and seromas. Other people needed manipulation under anesthesia for restricted range of motion and persistent stiffness. Unsurprisingly, needing to go back to the operating room would contribute to dissatisfaction.
Now let’s examine which of the patient expectations were NOT fulfilled. Take a look at this chart. The left column shows patients who were not fully satisfied with their surgery while the right column shows patients who report being very satisfied.
Pay close attention to where the RED bars are located. These are what people marked as expectations not fulfilled. The expectations with the largest red bars include physical function, walking distance, climbing stairs, physical activities, physical endurance, longer standing, and preventing secondary impairments. Pretty much ALL of these relate to some type of persistent limitation to physical activity or physical function.
In fact, when we look at the very satisfied group, their biggest red bars were also in the same categories and include physical function, longer standing, and preventing secondary impairments. The authors write that in general, the not fully satisfied patients were older, had more comorbidities, had worse range of motion postoperatively, and showed significantly lower patient reported outcomes measures.
So after reviewing this study, it’s apparent that meeting certain expectations is crucial for high patient satisfaction. And depending on how you look at it, surgery does an okay job. 40% of patients had expectations exceeded and 34% of patients had expectations met. That’s three quarters of patients with positive results.
But this is a major procedure and going in with a 25% chance of being dissatisfied seems really high to me. And I’m not saying it’s the technical skills of my surgical colleagues, they really do an amazing job. I think it has more to do with expectations going into surgery.
Keep in mind that the expectations that were least likely to be met were those pertaining to knee-related activities and physical function. Patients who felt that knee replacement surgery did NOT improve these activities reported lower satisfaction levels with the procedure.
And because of all of this, there is a growing emphasis by physicians to assist patients in establishing realistic expectations about the potential outcomes of surgery. One of these areas is counseling around knee-intensive activities, such as climbing stairs, gardening, dancing, squatting, and playing sports. Patients who expect improvement in these areas but do not achieve it are much more likely to report dissatisfaction with the outcome of their surgery.
So how can you use the data from this study to help you decide if you would benefit from a knee replacement surgery? I think it all goes back to the results from this chart. Knee pain was found to be the key expectation most successfully achieved in both satisfied and unsatisfied patient groups. Therefore, if your primary symptom related to arthritis is pain, a knee arthroplasty may be a very effective treatment option to achieve a significant reduction in symptoms.
But I have many patients that tell me that it’s not the PAIN from the arthritis that bothers them, it’s the limitations to physical function and physical activity. These are the people that may seriously want to think about whether a knee replacement surgery is the right option. And this is because the key expectation LEAST likely to be met was related to physical function. This was consistent across both satisfied and unsatisfied patient groups. People who have high expectations for knee-intensive activities are more likely to experience DISSATISFACTION if those expectations are not met.
Of course, every individual has unique circumstances and requirements, and their symptoms will vary. My goal is not to tell you whether you need or don’t need a knee replacement surgery. Rather it’s to help provide a framework on how to approach making a decision.
Ultimately, getting knee replacement surgery is a personal decision. It is not a decision that should be made by your physicians, nor by your x-rays. It should be based on your symptoms and how it affects your daily activities and your daily life. If you’ve exhausted most treatment options and continue to have pain, yes, a knee replacement surgery may make perfect sense for you. But if you have osteoarthritis - even severe grade 4 osteoarthritis - and are still fairly functional, you do not have to have a knee replacement surgery. You can consider non surgical options such as muscle strengthening and injections to control symptoms.
Patient Testimonial - Living With Osteoarthritis
I’d like to end this long discussion by sharing a success story of one of my patients. Her story is not unique and can be replicated. I’ve made many patients make similar transformations to their health and quality of life. You can do the same.
My patient was in her mid 60’s. She was unable to walk, unable to work, and unable to enjoy her time with family and friends. This was all because of pain and functional limitations from severe knee osteoarthritis. And she tried everything. Physical therapy and chiropractic care. Cortisone shots. Hyaluronic acid injections. She tried medications and creams and massages. Everything helped a little, some more than others, but she was still in excruciating pain.
Discouraged, she was contemplating a knee replacement surgery. But the timing just wasn’t right. Who was going to help her and her family? She couldn’t take time off work either. And the rehab scared her. She came to me for a second opinion and admitted her lifestyle was a mess.
But after our visit, she had a HUGE revelation that changed her life. Her knee pain slowly resolved. She had better function, more mobility. She exercised more and got her independence and her life back. So what was the secret? My patient started taking her diet and her weight SERIOUSLY.
She cut out processed meats and decided to eat mostly fish. No more fried foods and no more processed foods. Lots of vegetables. She still snacked, but opted for nuts and seeds. She also cut out a lot of added processed sugars and opted for natural foods like fruit.
My patient also implemented one of my favorite and easiest weight loss and appetite suppressing tricks. She started drinking two glasses of water prior to every meal. This helps in several ways: it can make you feel full, serving as an appetite suppressant; it provides a calorie-free option compared to sugary drinks, reducing your overall calorie intake; and it supports your metabolism and bodily functions through proper hydration. Often, we mistake thirst for hunger, so drinking water may also help avoid unnecessary eating.
All of these interventions helped my patient lose 25 pounds in the first six months. Each pound she lost meant 4 TIMES less weight going through her knees. This translates to 100 pounds LESS FORCE going through her knees with every step.
She was able to walk more, 10 minutes at first, but eventually built that up to 35 minutes daily. Her goal was to be able to get to 1 hour walks with her husband. She was actually surprised that the walks gave her MORE energy. She felt empowered for the first time in years.
She started doing weight training to increase her quadriceps and gluteal muscle strength. She had to do body weight exercises at first, but then was able to start adding light dumbbells. One day, she realized she was able to go up and down stairs without any pain. Previously, this was unimaginable. Her family was amazed at her transformation.
Her friend asked her “Weren’t you thinking about getting a knee replacement?” Yes, she said. But not any more. She felt good now. And despite having severe bone on bone osteoarthritis, she was hoping to delay surgery for a long time.
I’m sharing this story because if you are suffering from knee arthritis, you can make these changes too. Believe in yourself like my patient believed in herself. She was determined to make a change, and she did.
Start by examining your diet. You can't out exercise a bad diet. Start slow and cut out all the unnecessary carbohydrates, especially the added sugars. Then cut out the fried foods. Natural foods only. Things that grow in the ground or from trees. Eliminate or minimize processed foods.
Make time for exercise and then slowly increase it. If this means a 5 minute walk, then start there. Add muscle strengthening exercises. Cardio is great, but it is not a substitute for muscle strengthening. Focus on body weight exercises and especially target the quadriceps and the glutes.
If you have pain, that’s okay. Expect some pain when you first start out. A pain level of 3 or 4 out of 10 is acceptable. Anything higher and you may want to try an occasional ibuprofen or acetaminophen to help reduce the pain so that you can exercise more. Some people find supplements like boswellia serrata or turmeric curcumin more effective. You can also try supportive knee braces like a neoprene knee sleeve or a hinged knee brace during exercise. Those with severe pain may want to consider an injection of medications into the knee to help alleviate pain so that they can start exercising.
The reason these changes work is because osteoarthritis is as much a metabolic disease as it is a wear and tear disease. Things like your weight, your diet, your blood sugar, cholesterol, triglycerides, all of these things directly affect our joints and our perception of pain. Correct these critical factors and you’ll realize that managing arthritis isn’t just about addressing joint damage, but also about improving overall metabolic health.
This holistic approach can lead to significant reductions in pain and inflammation, enhanced joint function, and ultimately a better quality of life. It has been three years since my initial consultation with my patient and she is thriving. You too can see similar results if you start making changes.
