Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, she calls on the expertise of Dr. James Wyss, M.D., P.T., an Assistant Attending Physiatrist in the Department of Physiatry at the Hospital for Special Surgery in New York City, to explain the causes of and treatments for knee pain.

Dear Dr. Pat:

I am 55 years old and have been very athletic my entire life.  I am 5’10” and played basketball on a team from fifth grade through high school.  I began running in college and have logged about 15 miles a week, unless I was training for a marathon, which I do about every 3 years.  For the last year I have had knee pain that is worse when I climb stairs.  It gets worse when I run, so I can no longer run.  I saw an orthopedist, who told me that I needed bilateral knee replacements because I have “bone on bone” in my knees.  He explained that I developed this problem because of “overuse” and because I just took NSAIDs for pain and kept running.  This has really affected my mood.  I am one of those people who needs to run.  I have gained 10 pounds and have trouble sleeping now as well. 

Why didn’t someone tell me that my lifelong interest in athletics and then in running would cause this kind of serious problem?

What actually happened?

Are there any options to knee replacements?

How long do these replacements last?

What kind of rehab will be best?

What kind of athletic activity can I do with artificial knees (if I have to have these)?

Kathy

A Healthy Joint (Representation). Credit: National Institutes of Health

An Arthritic Joint (Representation). Credit: National Institutes of Health

Dr. Wyss Responds:

Dear Kathy:

I’m sorry to hear that you are having knee pain and that this pain is interfering with your ability to maintain an active and healthy lifestyle. Fortunately, there are treatment options available that can help to relieve your pain and improve function.

Athletic activities or other activities that overuse joints can predispose you to joint injuries and the development of osteoarthritis (OA), but overuse is not the only reason why people develop OA (see next paragraph). Each week I see an equal number of sedentary and active individuals with knee osteoarthritis. It is important to note that those who lead an active lifestyle are often in better overall health and respond better to treatment.  Plus, the benefits of exercise (improved mood, sleep, heart, and lung function, just to name a few) far outweigh the potential risks of exercise.  So when my patients ask, “Should I stop exercising to save my joints?” I almost always tell them “no” and explain that I can help them prevent or treat muscle and joint pains, but I can’t help them to maintain their overall health if they are not exercising.

Osteoarthritis refers to the loss of cartilage that lines the ends of the bones that meet and form the joints of the body. When this smooth cartilage is lost, the joint no longer functions properly.  Stiffness, swelling, and pain can occur, and when the affected joint is a joint of the lower limbs, the ability to run or even walk can be lost.  These joint changes occur naturally with aging, and can progress faster due to genetic factors, obesity, prior joint injuries, overuse, and joint mal-alignments. 

Joint replacement serves as the final treatment option for severe joint OA.  Joint replacement for the hips and knees are considered to be a very successful treatment option, and the longevity—duration of time that these joint replacements last— has improved tremendously as surgical techniques have improved and newer prosthetic devices have been developed.  If your surgery is performed at a center of excellence and with a surgeon who routinely performs these surgical procedures, then 15- to 20 years is a reasonable expectation for longevity.

There are many alternatives to joint replacement, but these options are often most successful with mild to moderate severity of knee OA.  These conservative treatment options include activity modification, a therapeutic exercise program, often established by a physical therapist, and braces or orthotics to address biomechanical or alignment issues.  Oral medications for control of pain and inflammation can be tried, and I often prescribe topical anti-inflammatory creams and ointments to minimize some of the systemic side effects of oral anti-inflammatory medications. 

Joint injections are the next line of treatment. They can include cortisone injections to temporarily relieve pain and swelling.  Hyaluronic acid (HA) injections, also known as joint lubricant injections, provide an alternative injection option that is FDA approved for treatment of knee OA 2 times a year.  These injections can provide longer relief of pain and improvements in function than cortisone in the correct candidate and can avoid the side effects of cortisone (elevated blood sugar in patients with diabetes).  Platelet-rich plasma (PRP) is another injectable option that is processed from the patient’s own blood, and may offer results comparable or superior to HA injections in patients with early or mild OA.  Many physicians, scientists, and hospitals, such as the Hospital for Special Surgery (HSS) in New York City, are investigating disease-modifying treatments for use in osteoarthritis that would slow or stop the progression of the disease, but currently these treatment options are not available. 

If you do choose to have total knee replacements, your pain should decrease and function should steadily improve during your post-surgical rehabilitation, which begins immediately after surgery and will continue at an inpatient or outpatient rehabilitation facility depending on your personal needs.  After successful rehabilitation, activity modification is still recommended.  Examples of advisable activities include hiking, cycling, and swimming, as opposed to running.  Golf and dancing are permitted, and some surgeons will permit doubles rather than singles tennis.  Contact sports, impact sports, or “cutting” sports (which have lots of stops and starts, like soccer and basketball) are advised against.

Helpful Resources

Hospital for Special Surgery overview of osteoarthritis: http://www.hss.edu/condition-list_osteoarthritis.asp

Arthritis Foundation site, for additional education and treatment: http://www.arthritis.org/

“Informed Patient Tutorial” —many images to explain knee OA, surgery and recovery, and further advice for patients: http://www5.aaos.org/icm/PrintModule.cfm?module=icm005