Category Archives: Knee

The knee is a complicated joint and often affected by arthritis, bursitis, and tendonitis. This category discusses many of the different afflictions of the knee.

Prevention is the best treatment for osteoarthritis?

A work group called the Osteoarthritis Management Initiative (COAMI) met in 2012 to discuss osteoarthritis management and what could be improved.  The thrust of the meeting was aimed at developing new strategies for prevention of the disease.osteoarthritis-knee-2

Risk factors for osteoarthritis include obesity, aging, genetics, family history, major injury or surgery to the joint, and misalignment of the joint.

According to Dr. Rowland Chang, professor of medicine at the Northwestern University School of Medicine, rheumatology is where cardiology was in the 1950′s.  More attention should be placed on disease prevention.  That includes lifestyle changes. He states, “If we could wipe out obesity, … we might be able to prevent about one-third of all the knee osteoarthritis we have in the world.”

My comment is this: It’s an admirable undertaking but making people change their lifestyle is going to be difficult.  However, with the aging Baby Boomer population, it’s certainly worth a try.

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“Ooohhh, My Aching Knee!” Insider Secrets on How You Can Get Relief Quickly and Easily!

When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.

Know Your Knee!knee-arthritis

The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.

Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.

Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a “torn cartilage”.

There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.

Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.

Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.

Is it bursitis… or tendonitis…or arthritis?

Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.

Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.

Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.

The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.

Knock out knee arthritis… simple steps you can take!

Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.

While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.

Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.

So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.

Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.

Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution… make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated… so buyer beware!

Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.

Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.

Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.

Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.

The technology that will revolutionize our approach to knee osteoarthritis is the use of mesenchymal stem cells.  These are stem cells derived from “non-blood” tissues such as fat, bone marrow, or even the lining of the joint. Studies in both animals as well as humans have shown great potential for these cells to regenerate cartilage.

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Osteoporosis Drugs May Benefit Patients With Knee Osteoarthritis

Lynda Williams writing in Medwire reported, “Research adds weight to reports that patients with knee osteoarthritis may experience benefits in pain or progression relief from bisphosphonate treatment.”

osteoarthritis-knee-2Bisphosphonates are drugs typically used to treat osteoporosis.osteoporosis Investigators who analyzed “data from the National Institutes of Health Osteoarthritis Initiative cohort shows that patients who used bisphosphonates  for 3 or more years over a 5-year period achieved a significant reduction in rating scale pain scores at years 2 and 3 compared with nonusers, after adjusting for baseline levels of pain and analgesic use.”

The findings were published in the Annals of Rheumatic Diseases.

Comment: Killing two birds with one stone…

 

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New Osteoarthritis Drug Slows Cartilage Wear?

The Holy Grail for osteoarthritis treatment is a disease modifying osteoarthritis drug.  This article talks about one possibility.

Kevin Deane writing in MedScape reported on a study from Belgium published in the Annals of Rheumatic Diseases. In this randomized, double-blind, placebo-controlled trial, called SEKOIA, Yves Reginster and colleagues used strontiumstrontium ranelate at either 1 or 2 g daily compared with placebo in 1371 patients with grade 2 or 3 knee osteoarthritis, as defined by Kellgren and Lawrence, with a joint space width of 2.5-5 mm. Patients were followed for 3 years, and outcomes included x-ray changes in joint space width, overall health related to osteoarthritis as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and pain as measured on a visual analog scale.

Treatment with strontium ranelate at a daily dose of 1 or 2 g was associated with a statistically smaller reduction in joint space width on plain x-rays. Treatment with the 2-g/day dose was also associated with improved health status related to osteoarthritis, as measured by the overall WOMAC score (P = .045) and a WOMAC subscore of pain (P = .028). The WOMAC subscore for physical function and knee pain as measured by the visual analog scale trended toward improvement in patients treated with the 2-g/day dose but did not reach statistical significance.

Reginster and colleagues concluded that treatment with strontium ranelate at daily doses of 1 or 2 g is associated with a significant reduction in progression of radiographic joint space width, and at 2 g/day with an effect on overall health associated with osteoarthritis.

Comment: Strontium may be effective.  It is already used to treat osteoporosis in Europe.  However, it has potential side effects including: deep vein thrombosis and a potentially fatal skin condition called Drug Rash with Eosinophilia and Systemic Symptoms (DRESS syndrome)

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Pain after knee replacement predicted by the presence of other conditions

Lynda Williams writing in Medwire reported, “Research may help physicians give patients who are undergoing total knee arthroplasty (TKA) a realistic expectation of surgery outcome based on their overall physical and mental health,” according to a study published in Rheumatology. knee-joint-replacement-surgery

Investigators found that “the likelihood of pain 2-5 years after primary or revision TKA was significantly influenced by a wide range of co-morbidities including heart disease and depression.”

it’s clear that a patient’s state of mind has a tremendous influence over the outcome of any disease or surgery.

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Stem Cells And Scaffolds For the Treatment Of Osteoarthritis

Osteoarthritis is the most common form of arthritis affecting more than 20 million Americans.  It is a disease of articular (joint) cartilage.

Normal cartilage  consists of a matrix constructed of a mixture of proteins,  sugars (proteoglycans), water, and collagen. Inside this matrix sit chondrocytes, cells that actually manufacture the matrix they sit in.

Under normal situation, cartilage is capable of withstanding both compressive forces as well as shear forces.  It deforms when loads are placed on it and then  expands to its normal contour once the load has been removed.

When cartilage is damaged as a result of trauma, injury, or other means, a change occurs in cartilage.  Chondrocytes produce destructive enzymes; the underlying bone deforms,  and the lining of the joint, the synovium, produces cytokines, protein messengers that stimulate inflammation.

The end result is wearing away of cartilage accompanied by chronic inflammation, and deformity related to abnormal mechanics of the joint.

To date, the treatment of osteoarthritis has been largely symptomatic using non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, and joint injections of either corticosteroid or hyaluronic acid.

The rapid development of stem cell science has shown promise as a treatment that may restore joint integrity by regenerating cartilage.

A caveat: The proper application of stem cells is not merely injecting stem cells into a joint and hoping for the best.

Multiple attempts by various laboratories have searched for a method of introducing stem cells along with a scaffold to enable stem cell multiplication and growth in an organized fashion that will best stimulate cartilage regeneration. A whole new branch of basic science, termed “tissue engineering” has been used to describe these ventures.

An excellent review of the current state of the science was published by the Harvard Stem Cell Institute.

(Willerth SM, Sakiyama-Elbert SE. Combining stem cells and biomaterial scaffolds for constructing tissues and cell delivery.)

The authors reviewed the literature regarding types of scaffold materials that had been studied.

These included natural biomaterials such as collagen, fibrin, silk, sugars, algae cell walls, hyaluronan, and chitin as well as synthetic platforms such as various polymers, peptides, and ceramics.

These scaffolds are generally “seeded” with growth factors that stimulate stem cell multiplication and division while protecting the stem cells in the hostile environment of the arthritic joint.

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Does Acupuncture Work For Arthritis?

The ancient healing art, acupuncture, has been the topic of numerous scientific studies to determine its efficacy.  In particular, acupuncture has been examined as a treatment for osteoarthritis.  The most complete study of acupuncture was a meta-analysis of data from more than 29 randomized controlled trials of acupuncture for chronic pain. (Vickers AJ, et al. Arch Int Med.September 2012)acupuncture-knee

The study found that patients receiving acupuncture had less pain than controls and acupuncture was statistically superior to both sham and no acupuncture controls for the treatment of osteoarthritis.

The study concluded that acupuncture is a reasonable referral option for patients with pain due to OA.

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Joint replacement surgery associated with heart attack risk

Jim Morelli writing in Arthritis Today commented on a new study published in the Archives of Internal Medicine.

joint-replacement-surgery“We found that total hip and knee replacements substantially increase the risk of heart attack during the first two weeks, in particular in patients older than 60,” says lead study author Arief Lalmohamed, a researcher in the department of pharmaceutical sciences at Utrecht University in the Netherlands. “We learned from this study that we need to focus more on preventing cardiac outcomes following this major surgery.”

The study relied on national registry data on about 95,000 Danish patients who underwent total hip replacement or total knee replacement surgeries between 1998 and 2007. The average age of the hip patients was 72, while the average age of the knee patients was 67. The researchers found that during the two weeks immediately following each surgery, heart attack risk rose sharply – 25-fold for heart-attack-in-hospitalhip patients and 31-fold for knee patients, compared with similar people in the Danish registries who did not have these surgeries.

After two weeks, heart attack risk dropped dramatically – although the overall risk of heart attack after hip replacement surgery remained elevated for six weeks. Researchers also found that the association between hip and knee replacement surgeries and heart attack was strongest in those 80 years or older. They found no significantly increased risk in patients younger than 60.

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What are the approaches to treatment of osteoarthritis of the knee?

There are multiple treatment approaches for osteoarthritis (OA) of the knee.

osteoarthritis-knee-2The most important to start with is weight loss and patient education.  Without these, other therapies won’t work.

Analgesics such as acetaminophen may work for mild disease and non-steroidal anti-inflammatory drugs(NSAIDS) can be used for more symptomatic disease. The use of the latter category of drug needs to be tempered with the knowledge that potential gastrointestinal and cardiovascular side-effects are associated with these medicines.  Topical NSAIDS may be safer.

Alternative therapies such ass glucosamine/chondroitin, acupuncture, and so on, serve a complementary role.

Exercise and physical therapy, and, if necessary, braces, orthotics, and other assistive devices may be helpful.

Injections of glucocorticoids and viscosupplements can provide significant palliative relief.

Guided mesenchymal stem cell layering is a technique that can provide symptomatic relief, potentially regrow cartilage, and delay the need for surgery.

Total knee replacement is to be considered for patients with end-stage disease.

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Do lubricants work for knee osteoarthritis?

A recent meta-analysis study indicated that lubricant injections for knee osteoarthritis (OA)are no more effective than placebo.

Hogwash!

Lubricants, known as hyaluronic acid (HA), have been used in the United States since 1997 for the treatment of symptomatic knee OA.viscosupplement

A very large meta-analysis study showed that these substances provided pain relief within 5 to 13 weeks after injection.  Improvement was 28-54% for pain and 9-32% for function.

The efficacy was comparable to that achieved with non-steroidal anti-inflammatory drugs and longer term than that seen with injections of steroids.  Steroids do work quicker though.

HA is a major component of normal synovial fluid and provides help with load absorption and also helps with lubrication.  HA may also have anti-inflammatory properties.  There are some hypotheses that suggest HA stimulates synovial cells to produce synovial fluid, stimulates the growth of cartilage cells, and prevents cartilage degradation.

HA should be administered using ultrasound guidance for the best results.

In our practice, we use Supartz.  It seems to work well with very few if any side-effects.

 

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