Many people experience knee problems during their lifetime. It hinders them in their daily lives and reduces quality of life. If there is no obvious trauma, and the knee does not lock up, you can calmly wait for 6 weeks. If necessary, you can take Naproxen or Diclofenac for a few weeks.
But what if the knee pain does not go away?
It’s always wise to have a good diagnosis before starting any specific treatments. In Spain, a MRI scan or ultrasound is often made quickly, but above the age of 35 it is better to start with a standing (i.e. loaded) X-ray of the knee in 2 directions, anteroposterior and lateral views. With this X-ray all 3 compartments of the knee can be evaluated and joint narrowing is easy to see.
Osteoarthritis is the same as ´artrosis´ in Spanish and has 4 levels: from little narrowing (grade 1) up to full narrowing (´bone on bone´, grade 4). These X-rays should be combined with a physical examination done by an orthopedic surgeon – knee specialist.
With no signs of osteoarthritis on the X-rays, suspicion of meniscal or ligament problems may be present. In that case a MRI scan is recommended, again with an adequate physical examination before.
Conservative treatment
Your orthopedic surgeon starts with some general recommendations like training of the quadriceps muscles, losing some weight, changing the (sport) activities and using painkillers for the ´bad´ days. A physiotherapist can help you with many of these treatments.
Even with a meniscal tear without displacement and locking complaints it´s always better to stay conservatively for the first 6 months. In 2013 a famous paper in The New England Journal of Medicine (Sihvonen et al.) concluded that, with degenerative medial meniscus tears in the age group 35-65 year, they advised not to perform a partial meniscectomy. And, even worse, with partial removal of a degenerative meniscus tear you can accelerate osteoarthritis of the knee. Arthroscopy of the knee is only indicated in acute, mechanical tears in the young age group and without any signs of osteoarthritis.
But what to do if conservative treatment fails?
The next step could be a cortisone injection in your knee. This gives pain reduction in the first 6 weeks, but often causes dysregulation of the sugar level and hot flashes. Besides that, cortisone is not good for the cartilage quality if you inject it in the knee more than 2-3 times a year. Another option is an injection with Hyaluronic Acid or Platelet Rich Plasma (PRP). The results in the literature of the latter two are mixed. Hyaluronic acid works for 6-12 months in some studies, while no difference is found in others. The same goes for PRP, this effect seems to last longer, but unfortunately not in all patients. A new treatment is the infiltration of Autologous Protein Solution (APS, N-Stride), in 85% of the patients with mild osteoarthritis of the knee the reduction of pain lasts 3 years! New research about infiltrations will follow the next few years I expect, but at this moment it´s definitely worth to give it a try to postpone surgery.
And with grade 3 or 4 osteoarthritis of the knee?
Discuss with your orthopedic surgeon all the treatments you have tried before. Was it sufficient to postpone surgery? How is your general condition? Do you have hip problems? Do you have pain at night? What is your maximum walking distance without pain?
Maybe replacement surgery could be the next step. And hopefully it can be done with a ´smaller´ partial knee replacement if only one knee compartment is involved. If not, a total knee replacement is the first choice.
Nowadays surgery is done with one night hospital stay, full weightbearing 4 hours after surgery and walking with1 crutch after 2 weeks.
And important: today the survival of knee replacements is more than 95% after 15 years and the myth that a knee prosthesis cannot be revised is not true. Especially a partial knee prosthesis can be converted in a total knee replacement easily.
But the take home message must be: it all starts with a good diagnosis by an orthopedic surgeon specialized in knee problems.
See you soon at Compass Clinic Estepona, Dr. Joris van der Lugt
Literature
Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear (Raine Sihvonen et al.), N Engl J Med 2013 Dec 26;369(26):2515-24.
Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus (Ph. Beaufils et al.), Knee Surg Sports Traumatol Arthrosc 2017 Feb;25(2):335-346.
Intra-articular corticosteroid for knee osteoarthritis (Peter Jüni et al.) Cochrane Database Syst Rev 2015 Oct 22;2015(10):CD005328.
Platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis: a meta-analysis (Jia Zhu Tang et al.), J Orthop Surg Res 2020 Sep 11;15(1):403.
Autologous Protein Solution Injections for the Treatment of Knee Osteoarthritis: 3-Year Results (Elizaveta Kon et al.), Am J Sports Med 2020 Sep;48(11):2703-2710.
Outcomes after joint replacement 2003 to 2020 (Ben-Shlomo Y et al.), The National Joint Registry 18th Annual Report 2021 London
