Today’s blog is a high-level, but significant overview, of what are the significant, non-surgical treatment options available for knee osteoarthritis. So, knee osteoarthritis is without a doubt one of the most common things that I see every single day in the clinic, and it’s significant enough where there’s quite a few different treatment options available. It’s a matter of understanding what works, what doesn’t work, what’s worthwhile for patients to pursue, and what, as physicians, can we really offer to maximize the health and wellness for our patients.
There are a couple of very initial things that every single individual that has knee osteoarthritis should be focused on before they even start getting treated from a medical perspective. Without a doubt, if there is any degree of excess body weight, weight loss and getting to an ideal body weight is of critical emphasis. Every pound that’s reduced can help reduce the weight on the knees by three to four pounds, so that can be significant in terms of reducing pain. If an individual has to lose 10 pounds, that’s a significant amount of stress reduction on the knees.
In a somewhat related fashion, improving the biomechanics is also essential. Strengthening, via either physical therapy or with a trainer or on one’s own, in particular, focusing on hip and core strengthening. The reality is that the knee, the hip, the back, the ankle, these are all connected in a very finely-coordinated motion that we’ve developed over thousands, if not tens of thousands of years. The way that we live in modern society is we’re too sedentary. Sitting too much leads to many people, if not most people, having some degree of hip weakness and core weakness. In the normal course of daily activity, walking, gait, running patterns, then leads to excess stress on the knees. The normal transfer from the trunk and hips down to the knees because of that weakness leads to more stress on the knees. Anything that can help to strengthen the hip and the core can also help with knee arthritis-related pain as well.
Also essential is improving posture and symmetry. This may sound relatively minor, but the reality is that we all have a slight degree of asymmetry from one side to the other side. We all have slight deviations in posture from the ideal. Those slight deviations, when applied over months to years to decades, leads to more stress on individual body parts including the knees. Trying to correct those kind of issues is of essential importance as well. Egoscue is a nationwide clinic that has a focus on posture-related stuff and I think that’s very helpful also.
Additional things that can be tried even before you get into my office would include maximizing joint healthy supplements that we know can help with osteoarthritis pain. That incudes glucosamine chondroitin, which can help roughly 50% of people that take that. Omega-3 can help with the mild degree of inflammation that you see in osteoarthritis as well. And turmeric, which has curcumin, can also help in terms of pain and some of the mild inflammation that you see in osteoarthritis. The benefit of these is that if that means an individual requires less pain medication, less anti-inflammatory medication, and that allows them to function more, do a bit more exercise, maintain their strength, reduce their weight. These are low-risk supplements. I like the idea of utilizing those in place of chronic anti-inflammatory medications. Other complementary treatments, including chiropractic, acupuncture, massage, and other low-risk options that can help with pain relief are certainly worthwhile trying for knee osteoarthritis.
Despite the above treatments, if an individual is still having pain in their knees, what’s next? From a non-surgical standpoint, the traditional injections include steroid injections or viscosupplementation injections, or gel injections. I’m not a fan of steroid injections for wear-and-tear arthritis for a number of reasons. Number one is that they’re short-lived in terms of benefit. Number two, they have the potential, if utilized too often, to actually damage cartilage, bone, and soft tissue. In addition, they don’t even help with improving things like stability and other other key physiologic issues that affect the knee.
Viscosupplementation injections can help in mild to moderate osteoarthritis. They tend to be a mild treatment option but are low-risk and can help as well. The next set of injections that I think are worthwhile really thinking and focusing on for knee osteoarthritis are orthobiologic treatments.
While this discussion is not about surgery, it is useful to understand the a few issues regarding knee surgery. Total knee replacement is a separate discussion, of course, and I think most knee osteoarthritis patients can be treated relatively well with the potential to avoid total knee replacement, but there is that need in some people. Arthroscopy, however, is one of the most common knee surgeries done for knee osteoarthritis. The reality is that there are multiple studies showing that routine knee arthroscopy, or a clean out surgery, is no better than just physical therapy. This is not recommended by the largest orthopedic professional associations. It’s actually not even allowed in certain countries where they try to manage healthcare costs because there’s no evidence that it’s of significant benefit in most people compared to just improving biomechanics via physical therapy.
A better option are the orthobiologic treatment options. Orthobiologics essentially means, ortho meaning related to the musculoskeletal system and biologics meaning treatments that are coming from cell-based treatments and biologic tissues. There are a number of different options. What’s nice about orthobiologic treatment options is number one, they can help with pain, they can help with inflammation, they are generally autologous, meaning coming from oneself, and so they are low-risk in terms of infection and reactions. In addition, besides treating pain, utilized in an appropriate fashion, they can actually help improve stability and function as well. You can do that because under image-guidance, you can inject orthobiologic treatments into tendons and ligaments. And if you can improve the chronic laxity, degenerative laxity, that occurs in a degenerative knee osteoarthritis condition, you can actually improve the stability in that knee joint as well, which will improve function and it will improve pain as well.
In terms of orthobiologic treatments, there are a number of different ones that are available right now. There are three very common ones that you may hear about. Platelet-rich plasma is probably the most common one that’s used at this time. This is essentially a treatment where you take a quantity of blood from an individual, from a blood draw, concentrate that down into a high concentration of one’s own platelets and then inject that into the tissue that needs to be treated. Whether that’s just a joint or the soft tissue structures as well, the data out there shows that this is a better treatment option than the viscosupplementation or gel injections. It gives not only more pain relief, it gives longer-lasting pain relief. This is a good moderate-level treatment option for knee osteoarthritis. I’ve had good results even in more advanced knee osteoarthritis. But certainly, a fairly reliable treatment option for mild-to-moderate knee osteoarthritis.
You can then escalate to what’s called bone marrow aspirate concentrate-derived stem cells. This is essentially a treatment where you take an individual’s own bone marrow from the back of their iliac crest over their pelvis, concentrate that down into a very high-concentrate of a number of different cellular materials, including mesenchymal stem cells, hematopoietic stem cells, and a number of other cell lines and growth factors which can then be injected into the joint, soft tissue, bone, and other parts of that degenerative knee condition. This is a good option for moderate to more advanced knee osteoarthritis. In my experience, but also in the published literature, this is a treatment option that can work in even advanced knee osteoarthritis. It’s not uncommon that patients come in and say that they’ve been told that they have bone on bone knee arthritis based on a X-ray, and yet when you have them flex and extend their knee, they are able to still get pretty good range of motion. That kind of individual can still respond quite well in terms of pain, in terms of reducing chronic inflammation, in terms of improving function, and maintaining a high-quality life as well.
The last one to mention are the birth cord fluid treatment options that people are hearing about. That includes amniotic fluid and umbilical cord fluid. These have been miscategorized as stem-cell treatments. The reality is that multiple sources have looked at whether there are any live cells in these products and the reality is that there are no significant live cells in these products in order to be sold in the United States. And that’s because, for safety reasons, in order to be utilized by physicians in patients, since it’s a foreign material, these are processed in a manner that essentially kills off all the cells and then, when it’s rehydrated to be used at the bedside, it will further kill off any remaining cells that were able to survive that initial screening process. While the birth cord fluid products are not a true stem-cell treatment, because they don’t have any live cells, they do have growth factors and they’re likely equivalent to a platelet-rich plasma injection, except coming from somebody else. These treatments can still be helpful, but I still think those first two options, platelet-rich plasma and bone marrow aspirate concentrate stem cells, are better orthobioligic treatment options.
That is really just scratching the surface but it’s a pretty good high-level overview in terms of what’s available from a non-surgical treatment standpoint. The reality is that compared to where we were 10 years ago, we’ve really come light years forward. With ongoing data collection efforts, and now results being published in the peer-reviewed literature showing effectiveness of these treatments. As time goes on, you will be hearing more and more about these treatments. They have a legitimate use. They need to be regulated in a appropriate way professionally, but these are good treatment options for knee osteoarthritis and for people that have chronic pain, knee pain that’s preventing them from functioning at a higher level. These are excellent treatment options to consider in anyone who has knee osteoarthritis.
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