Treating Chronic Knee Pain Without Surgery

Author: Joshua Steere, MD

In my practice I see many patients struggling with chronic knee pain from osteoarthritis. Osteoarthritis occurs when the knee’s natural cushion of cartilage wears away due to stress, strain, age, inflammation, or injury. This leads to pain which can make it difficult to enjoy life to the fullest. Fortunately, many non-surgical treatments can help reduce the symptoms of osteoarthritis. Used individually or in combination, these treatments can reduce pain, increase mobility, and improve quality of life.

The treatment options described below are based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS), the American Association of Hip and Knee Surgeons (AAHKS), and the American College of Rheumatology. For more information about these treatments and other treatment options for knee arthritis, please see the links at the bottom.

Low-Impact Aerobic Exercise ***

When we experience pain, the natural inclination is often to rest or resist moving the painful joint. In cases of knee osteoarthritis, however, exercise can actually make the knee feel better. Many find it surprising that low-impact exercises are part of the first-line treatment for knee arthritis and have some of the best supporting evidence for symptom relief.

Low impact aerobic exercises combine two essential elements of movement that can help knee pain. The first is “low impact” – meaning exercise that will move the body without placing unnecessary stress on the joint. Cycling, using an elliptical trainer, and swimming are all great examples of low impact exercises that avoid high-impact stresses such as twisting, jumping, or deep bending. The second important element is “aerobic”, which means sustaining the activity long enough (usually 20-30 minutes) to increase the heart rate and improve endurance in the muscles. Starting a low impact aerobic exercise regimen, ideally 3-4 times a week for 20-30 minutes per session, can reduce pain and improve function in knees with osteoarthritis.

Physical Therapy ***

Working with a physical therapist can also help alleviate knee pain. It is very common for people to overcompensate with their knees when doing activities such as standing up from a chair or walking up or down stairs. Additionally, if muscles in the hips, back, or core are weak or not working optimally, the knees often bear an extra load. Improving the function in all muscles and joints in the legs can reduce the strain on the knees. Physical therapists can evaluate the way people are walking and moving to help optimize function and avoid excessive strain. Working with a physical therapist can be beneficial for the knees as well as the rest of the body.

Medication

NSAIDs***

NSAIDs are often part of the first-line treatment of knee osteoarthritis. NSAIDs is an acronym for non-steroidal anti-inflammatory drugs. These medications have some of the strongest supporting evidence for improving symptoms of knee osteoarthritis. NSAIDs work by reducing painful inflammation without the use of steroids or narcotic opioids. Common over-the-counter NSAIDs are ibuprofen (also known as Advil, Motrin) and naproxen (also known as Aleve). Some NSAIDs are available only through a prescription, including celecoxib and meloxicam. These medications are often best taken before or after activities known to increase pain, however some people take them on a more regular basis if pain is persistent. While NSAIDs are safe for many people to take for a short duration, they are not safe for everyone depending on medical problems and other medications. Talk to your doctor to determine if these medicines are right for you.

Acetaminophen

Acetaminophen (also known as Tylenol) can also provide pain relief for knee osteoarthritis. However, studies have not shown as strong of a benefit with acetaminophen as with NSAIDs for knee arthritis. Sometimes acetaminophen can be taken in conjunction with NSAIDs for additional pain relief. Talk to your doctor to determine if acetaminophen could be a safe, helpful option for you.

Other Medications

Other classes of medications such as narcotic opioids, glucosamine, chondroitin, and other supplements have less predictable outcomes for knee pain from arthritis and are not routinely recommended for treating knee osteoarthritis.

Injections

Corticosteroid injections (sometimes referred to as cortisone injections or steroid injections) into the knee joint can provide short duration pain relief in knee arthritis. Cortisone is an anti-inflammatory medication that can help reduce acute aggravation in the joint, however it does not reverse or restore damaged cartilage and is less effective for chronic daily pain or more advanced forms of arthritis.

Weight Management

Excess body weight increases strain on the knees. Since one of the goals in treating knee osteoarthritis is to reduce strain on the knee, managing weight can be a very effective way to reduce pain.

When walking on a level surface, the knees absorb about 1.5 to 2 times our body weight. That can increase to as much as 4 to 5 times our body weight when going up and down stairs or with deep bending. This means small increases in body weight can magnify pain from knee arthritis. Fortunately, this also means that a small amount of weight loss can reduce strain and pain in the knees.

While knee osteoarthritis may limit the intensity and frequency of exercise options, there are still evidence-based ways to effectively lose weight with little or limited exercise. Changes in lifestyle and diet can make significant impacts. To help with this, we partner with area doctors who can help our patients design individualized weight loss plans.

Activity Modification

Activity modification can also help reduce strain on the knees. The knees experience the most strain with activities like going up and down stairs, climbing ladders, or squatting down. If certain activities or exercises cause knee pain to flare up, finding alternative ways to perform these activities can help reduce the frequency of knee pain. As mentioned above, a physical therapist can also be very helpful in teaching modified or optimal ways to perform activities while easing knee stress.

Assistive Devices

Using an assistive device such as a cane or a walker can help with a flare in knee pain. These can shift the body’s center of gravity away from the affected side and reduce the strain on the joint. Assistive devices can also help reduce the risk of falls if the knee gives out due to pain.

Braces

Sometimes a knee brace can help the knee feel more stable. One particular type of knee brace, called an “unloader” is designed for knee osteoarthritis that affects one side of the knee more than the other and can shift some of the force away from the painful side of the knee and toward the less-affected side. The effectiveness of these braces depends on the type of arthritis in the knee and how well it fits the leg.

*** Denotes “Strong Evidence Recommendation” by the American Academy of Orthopaedic Surgeons

If you are struggling with knee pain, please call (215) 600-4714 to schedule a consultation with one of our specialists.

Links:

American Academy of Orthopaedic Surgeons (AAOS) - Clinical Practice Guidelines on Treatment of Osteoarthritis of the Knee

http://www.orthoguidelines.org/topic?id=1005

American Association of Hip and Knee Surgeons (AAHKS) - Patient Care Library

https://hipknee.aahks.org/relieving-hip-and-knee-pain-without-surgery/

American College of Rheumatology / Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis

US Department of Health and Human Services - Physical Activity Guidelines for Americans

https://health.gov/our-work/physical-activity/previous-guidelines/2008-physical-activity-guidelines

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