Managing Knee and Hip Arthritis - The non-surgical approach

Obviously not all knees and hips with wear and tear need surgery. In the early stages there are several things that can be done to slow the progress of the condition and possibly even lead to a degree of recovery.


Weight control and Physiotherapy

A study in the British Medical Journal (Jenkinson, August 2009) confirmed that "A home based, self managed programme of simple knee strengthening exercises over a two year period can significantly reduce knee pain and improve knee function in overweight … people with knee pain. A moderate sustained weight loss is achievable with dietary intervention…". This means that, often with the help of a dietician, it is possible to maintain weight loss and that this has a significant effect on knee pain and function in the majority of cases.

Physiotherapy focuses on maintaining range of motion in the stiffening knee, regaining the loss of muscle power and stamina and improving normal walking patterns. 

Whilst it is clear that doing exercise to lose weight will be very hard when knee pain restricts that exercise, it is important to remember that reducing calorie intake is even more important in this situation. If you cannot burn the energy off because the knee is too painful to exercise then it is imperative to reduce the energy being taken on board. This means reducing portion size and the quantity of high energy foods. 


Joint injection

Synthetic hyaluronic acid injection (Mr Arbuthnot uses Synvisc and Ostenil Plus): there is improving evidence that synthetic hyaluronic acid injection may be of benefit in early knee arthritis. It is made from a natural substance that lubricates and cushions your joint. Research has suggested that it can provide up to six months of knee pain relief with one injection.

How does it work?
In knees with osteoarthritis, the joint fluid (called synovial fluid) can break down and become more watery and not provide the shock absorbency your knee needs. Many surgeons believe that hyaluronic acid injections supplement your knee fluid to relieve the pain and improve the knee joint's natural shock absorbing abilities.

Side effects are uncommon but can include knee pain, stiffness and swelling or the build up of fluid in the knee. The most concerning risk is infection, especially if the injection is given into a joint. However, this is rare, particularly when carefully administered.


Steroid (corticosteroid)

Anti-inflammatory steroid injections do have a role in the temporary reduction of pain in joints with wear and tear inflammation. They are injected directly into the joint with care to avoid infection. Cortisone is a type of steroid that is produced naturally by a gland in your body called the adrenal gland. Cortisone is released from the adrenal gland when your body is under stress. They work by reducing the inflammatory process within the tissue/joint.

Side effects are uncommon but can include knee pain or 'cortisone flare,' a condition where the injected cortisone crystallizes and can cause a brief period of pain worse than before the injection. This usually lasts a day or two and is best treated by icing the injected area. Another common side-effect is whitening of the skin where the injection is given. This is only a concern in people with darker skin, and is not harmful, but patients should be aware of this. The most concerning risk is infection, especially if the injection is given into a joint. However, this is rare, particularly when carefully administered.


Physiotherapy

These highly trained practitioners can help significantly with maintaining range of motion and stability in joints and optimising the stamina and power of the surrounding muscles. Whether this therapy is to try to cope without surgery or in preparation for it, the benefits are significant. 


Exercise

Maintaining general health with cardiovascular exercise is important for everyone but many surgeons are concerned about the potential damage that could be caused by this to the joints - particularly of the knee, hip and ankle.

Running: The overall health benefits of cardiovascular exercise, such as running, are clear. It is also clear, that in certain circumstances, running can lead to overload injuries of muscles, tendons, and bone. It has not been established that running leads to degeneration of articular cartilage (osteoarthritis).

However, it is important to understand that runners with abnormal anatomy and those with significant previous injury are at increased risk for the development and progression of hip, knee and ankle osteoarthritis. It is also likely that athletes exposing themselves to very high levels of training (e.g. marathon runners) are also exposing themselves to a high risk of injury (up to 55% 1-year prevalence in one study - van Middelkoop 2008)

Resistance Training/gym work: In people with knee osteoarthritis pain, knee function, and knee performance (including maximum walking speed, time to stand from a chair, and balance) improve significantly following resistance training. This should initially be carried out in association with a physiotherapist

Low joint impact sports: Many surgeons recommend such sports as low impact cycling, walking and swimming for patients with lower limb arthritis. This is because of the way the cartilage is loaded with these sports. These activities allow the cartilage lining of the joint to work without the impact loading of other activities. Current research suggests that this allows the fluid within the cartilage to function in a certain way: the joint glides with lower friction on a liquid surface that is "boosted" by some of the water being slightly absorbed by the porous cartilage. This leaves the "cartilage matrix" briefly in a higher concentration that provides better lubrication and shock absorbency. Also, when loaded gradually, the fluid in the knee works as a "fluid film lubricant" that provides hydrodynamic lubrication.


Medication

Numerous medications have been developed to reduce pain and many of these are developed specifically for people with arthritis.

These include:-

  • Paracetamol
  • Opioids (and opiates) such as tramadol and codeine
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as voltarol
  • Analgesics directed at nerve pain reduction such as gabapentin
  • Local anaesthetics such as lignocaine
  • Glucosamine and Chondroitin

The best way to address pain control requirements is in close association with your surgeon and GP, gradually "going higher up the analgesic ladder" to stronger medications until control of pain symptoms is achieved. This should be in conjunction with the above recommendations.