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There is a 50-50 chance that, at some point in your life, you’ll develop osteoarthritis (OA). Not great odds, considering how much this joint condition can be disabling to you — affecting ambulation and many activities of daily living.
The pain and limited mobility in OA occur as the cartilage that cushions the space between bones wears away with age and overuse. Left bare of their padding, bones rub painfully against each other — particularly in the hands, spine, knees, and hips.
There are many options for managing the symptoms of knee OA, such as pain, swelling, and stiffness. But which options truly work? The American Academy of Orthopedic Surgeons (AAOS) last year updated its clinical practice guidelines for the treatment of knee OA after reviewing the scientific literature and assessing the benefits and harms of care options. Here’s a look at what they found.
Diet and exercise
When you have aching knees, getting up to exercise may be the last thing on your mind. But no therapy has a bigger, more consistent payoff than exercise, according to the analysis of the evidence-based literature. And you don’t necessarily need fancy equipment or gym membership. One study found that people with OA in one or both knees who simply participated in an organized walking program for eight weeks experienced an overall 39-percent improvement on a scale that measured their activity level, pain, and medication use. Meanwhile, similar patients in a comparison group who didn’t exercise experienced worsening symptoms.
A good exercise program for knee OA features low-impact aerobic training (such as walking or swimming) and exercises to improve balance and strength. Exercise can improve flexibility, range of motion, and muscle strength in the legs in addition to relieving pain and improving function.
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Combining exercise with a proper diet will help you maintain a healthy weight, too, which is another sound recommendation for people with knee OA. Lightening your load can relieve stress on the knees. Meanwhile, some research suggests that losing flab reduces blood levels of inflammatory factors that may worsen arthritis. While more study is needed, a modest amount of research shows that overweight people with knee OA who shed a few pounds — at least five percent of their body weight — have less pain and stiffness, as well as fewer limitations on daily activities.
Drug treatment for pain relief
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the medications with the best track record for treating knee OA, with at least 19 studies confirming their value for soothing joint pain. NSAIDs are available over the counter and by prescription, and come in pills or topical form that’s applied to the skin. Your doctor will prescribe the optimal choice for you. If oral NSAIDs upset your stomach, your doctor may prescribe a pain reliever called tramadol; most studies suggest it provides at least some relief from pain and stiffness from arthritic knees.
Meanwhile, if you take acetaminophen (Tylenol) to manage knee OA symptoms, you may need to rethink your regimen. The AAOS said acetaminophen was a reasonable choice for treating knee OA in its 2008 guidelines, but that recommendation was based on a maximum dose of 4,000 milligram (mg) a day. However, in 2011, the US Food and Drug Administration cautioned against taking more than 3,000mg daily because of concerns that the drug can cause liver damage at higher doses. What’s more, the limited research that’s been conducted on acetaminophen for knee OA has failed to find a significant benefit. The AAOS is now unable to say whether acetaminophen is a good choice for people with knee OA. If you take acetaminophen for pain, check to be sure your daily dose is safe.
Corticosteroidal injections are sometimes used for short-term pain relief, but AAOS couldn’t find conclusive evidence that they’re more effective than a placebo and can’t recommend either for or against the injections. Furthermore, regular injections can actually cause additional damage to the joint, and patients should have no more than four injections a year.
Similarly, the AAOS says too little good-quality research is available to recommend for or against the following therapies sometimes prescribed to treat OA of the knee and other joints:
• Most opioid drugs such as oxycodone and hydrococlone.
• Pain medications administered via skin patch.
• Injections of growth factors or platelet-rich plasma.
• Chiropractic and other forms of manual therapy.
• “Unloader” knee braces, which are supposed to unload stress on the knee joint.
Treatments to avoid
According to the AAOS, the weight of scientific evidence suggests that the following popular therapies are not effective for treating osteoarthritis of the knee:
• Hyaluronic acid. The AAOS formerly called scientific support for injections of this lubricant into the joint “inconclusive,” but now strongly recommends against its use for knee OA because of its lack of effectiveness.
• Acupuncture. Any reduction in symptoms from pinprick therapy is too small to make a difference, studies show.
• Glucosamine and Chondroitin. Extensive research indicates that these popular supplements are no more effective than sugar pills for knee OA.
• Lateral wedge insoles. The AAOS says it “cannot suggest” the use of custom–made shoe inserts because of lack of evidence that they offer any relief from knee OA.
Surgery: Not always the best option
The AAOS recommends against undergoing an arthroscopy, or arthroscopic debridement, a surgical technique that uses a thin tube with a light and tiny video camera at one end to view the inside of the joint and remove damaged cartilage or bone. It also recommends against arthroscopy with lavage in which a surgeon “washes out” debris such as loose pieces of bone and cartilage from a knee joint. No reviews or studies showed that either procedure significantly improved OA symptoms compared with noninvasive therapies. The AAOS concluded that the risk of surgery and lack of effectiveness were sufficient reasons to advise against arthroscopy, with or without lavage, for people with OA.
Likewise, the AAOS failed to find adequate evidence to recommend or discourage a form of surgery routinely performed on patients with knee OA called arthroscopic partial menisectomy. However, a study in the New England Journal of Medicine published in May 2013 raised questions about the value of this procedure, which is performed to repair tears in the meniscus, the rubbery layer of cartilage that keeps the thighbone (tibia) and shinbone (femur) from crashing into one another. A torn meniscus can produce pain and stiffness and may also cause a knee to “lock” or give way now and then.
Meniscal tears are common in people who have knee OA and occur in about 35 percent of men and women over 65. However, for reasons that aren’t clear, these tears don’t cause symptoms in about two-thirds of people who have them. Nonetheless, when a meniscal tear is discovered in a person who has knee OA, doctors recommend a partial menisectomy to remove the torn portion of the cartilage. In the US, about 465,000 Americans undergo this procedure each year. The study found that OA patients who had their torn cartilage surgically repaired and then underwent physical therapy showed no difference in pain level, stiffness or limitations on daily activities compared with OA patients who had physical therapy and no surgery.
Going under the knife may be appropriate for some forms of joint pain, such as when damage caused by osteoarthritis is so severe the only remaining option is a total knee replacement, or arthroplasty, during which the disease or damaged joint is removed and replaced with an artificial one. But people with knee OA should consider surgery only after they’ve exhausted all other possible pain-relief treatments. More conservative methods may be just as likely to ease your pain and get you back up on your feet.
The bottom line
The truth is, there’s more than one approach to reducing the pain of knee osteoarthritis and improving function. What works for one person won’t necessarily work for another. Furthermore, just because a therapy isn’t strongly recommended by the AAOS due to inconclusive scientific evidence doesn’t necessarily mean that it should never be tried. It may mean simply that not enough high quality studies have been done to determine its effectiveness and more research is needed. However, you should never try an alternative option without your doctor’s consent. Consult with your doctor to find the best course of treatment that works best for you.
