My doctor has told me, my knee is arthritic and nothing can be done except taking panadol osteo and waiting until it is bad enough for me to have a joint replacement. Is this true?
The type of arthritis the doctor is talking about is osteoarthritis (OA) and is the most commonly diagnosed cause of knee pain in individuals over 50. It occurs because there has been cumulative (over many years), uneven (maybe due to a previous knee injury or maybe your parents didn’t give you straight legs) or excessive loading of the joint so the lining of the joint (cartilage) wears out and places more force through the bone. If your doctor has looked at your x-ray and said you have “bone on bone”, this does not mean there is nothing you can do. In fact, a recent study of 750 people over 50 found 90% had structural abnormalities on MRI, consistent with knee OA, but only 30% complained of pain. So, pain intensity does not correlate with the severity of change found on x- ray. As the knee joint cartilage has no nerve fibres, your knee pain is not coming from the wearing of the cartilage.
If the cartilage has no nerve fibres, why am I getting pain and what can I do to improve the pain?
The wearing of the articular cartilage abnormally loads many structures in your knee, which do have nerve fibres, so if you can increase the way your muscles (quadriceps [thigh] and gluteals [buttock]) work, you can decrease the load through the knee (it is a bit like changing the wheel alignment on a slightly worn car tyre). It has been shown that weakness of the quadriceps muscles causes increased patellofemoral (knee-cap) cartilage loss, tibiofemoral (thigh and shin bone) joint space narrowing and can lead to an inability to fully straighten the knee. Decreased quadriceps strength means you can’t go up and down stairs easily and you often need to use your hands when you get out of a chair. If the quadriceps muscle is stronger then the load on your cartilage will be reduced and the wear of the joint will be decreased. Increased quadriceps size on MRI in middle-aged individuals is associated with reduced knee pain at 2 years and reduced medial tibial (shin bone) condyle cartilage loss at 4.5 years from baseline. So, non-operative management of knee OA is very successful in improving symptoms of OA knee.
Another way you can improve your knee pain is by reducing your body weight. When you walk, 0.5x your body weight goes through your knee joint, when you go up and down stairs this increases to 3-4x body weight and when you squat there is 7-8x body weight going through the knee. Even a small decrease in weight will have significant effect on your joint load and hence your knee pain.
What can you do to help me improve my OA knee pain?
At McConnell Physiotherapy Group we can give you a tailored program, which is aimed at subtly changing the way you move, so the load through your joint is more evenly distributed. We make the program easy for you to do, requiring no equipment, so it can be at any time, in any place, taking no more than five minutes to complete, which should help your compliance to the program. Initially, it is essential we reduce your pain. We do this by using tape to unload the painful tissues in your knee, until your muscles are strong enough to diminish the load through these tissues. You will need to do the neuromuscular training program at least twice daily and when the symptoms have gone, you should continue the program daily as a maintenance or preventative strategy, just like cleaning your teeth, because your knee symptoms are managed not cured. This physiotherapy program has been recently investigated and been shown to be extremely effective in not only decreasing the OA knee pain but also positively changing the appearance of some of the abnormally loaded structures on MRI.
My doctor has told me I have a degenerative torn cartilage (meniscus) and need surgery, is this true?
Degenerative horizontal cleavage tears are present in 33% of the population >50 and, unless the tears are causing locking or undue swelling, surgical intervention usually accelerates the rapid decline of the knee symptoms to a total knee replacement. In fact, a recent study published in the New England Journal of Medicine examining the outcome of arthroscopic partial menisectomy versus sham surgery for degenerative meniscal tear in 150 people aged between 35 – 65, found after 12 months there was no benefit of the arthroscopic partial menisectomy over the sham surgery, and that physiotherapy was just as effective. Previous meniscectomy is a common accelerant for joint mal-alignment, causing a 6x increase risk of tibiofemoral OA compared with non-operated controls. If the meniscus is removed, the joint contact pressures increase by 100-300%.
So, if you have been told that you have a cartilage tear and you are over 40 years of age, there are many things we can do non-operatively that will help your symptoms. The degenerative tear is usually only painful when the tear is in the innervated posterior portion of the meniscus and the tear may occur if you have been squatting down gardening, or you twist suddenly, or you push something sideways with your foot. You will have trouble turning over in bed and you won’t be able to rest one leg on the other when you are sleeping. We will be able to show you strategies to improve your night’s sleep while the tear slowly heals.
If I need a knee replacement because my pain is too bad can you do anything beforehand to help me?
If you need a total knee replacement, the stronger your muscles are going into the surgery, the better your outcome. We can show you how to get your muscles stronger beforehand – this is called prehabilitation and you will benefit greatly from this knowledge during your rehabilitation.