Knee Arthritis Treatments

These instructions may help you get some relief from your knee arthritis.

What is knee arthritis?

Knee arthritis is damage to your cartilage due to years of strenuous activity, injuries, deformity, and/or inflammatory conditions (rheumatologic diseases).  The cartilage in our knee joints acts as a cushion. When patients have no cushion in their knee, the femoral bone abruptly impacts the tibial bone, which bruises the bones.  These bone bruises hurt.  Patients usually describe deep, throbbing, achy pain that gets worse with more strenuous activity.

Knee arthritis patients often describe "start-up pain".  When a patient with knee arthritis has been especially active, then sits down for a few hours, and then tries to stand up and walk again, they often have significant achy pain and feel like their knee will give out.

This start-up pain is classic for knee arthritis and a good indicator that it might be time to get a knee replacement.

 

Diagnostic test

Knee arthritis is typically diagnosed with a standing knee x-ray. Cartilage is about 90% water and appears on an x-ray as the space between the bones (joint space). A normal, non-arthritic knee x-ray (Fig. 1 shown below) will have 6-7 mm of cartilage or joint space in all 3 compartments (medial, lateral, and patellofemoral).

Fig. 1: Normal Knee X-ray 

An arthritic knee x-ray (fig. 2) may appear as if the femoral bone is touching the tibial bone (i.e., bone-on-bone arthritis in the medial compartment).

Fig. 2: Arthritic Knee X-ray 

Patients with knee arthritis do not typically need a knee MRI.  MRIs can be helpful to diagnose meniscal tears in patients without arthritis who may want to get a knee scope. Performing a knee scope for a meniscus tear in a patient who also has arthritis does not improve clinical outcomes.

 

Oral Medications

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

The AAOS guidelines recommend NSAIDs to improve function and decrease pain from knee arthritis.

Many NSAIDs are available over the counter, like:

  • Naproxen (Aleve)

  • Ibuprofen (Advil, Motrin)

Some NSAIDs are available only by prescription, like:

  • Meloxicam (Mobic)

  • Diclofenac (Lodine)

  • Celecoxib (Celebrex)

NSAID has four potential major complications:

  • Gastrointestinal events (gastric ulcers, GI bleeds)

  • Kidney damage (increase in creatine)

  • Cardiovascular events (hypertension, heart attacks)

  • Contra-indicated with blood thinners like Xalerto, Eloquis, and Coumadin

Some patients taking NSAIDs should consider taking misoprostol or a proton pump inhibitor (Prilosec, Nexium, Prevacid, etc.) to prevent GI issues.

The likelihood of having a complication from NSAIDs increases with longer duration and a higher dosage of NSAIDs. Patients should notify their PCP and/or cardiologist before taking these medications for more than a few days.  Patients with GI, kidney, or heart issues should not take regular NSAIDs.

Patients who take NSAIDs on a daily basis should consider stopping the NSAIDs for 3–4 days each month to give their bodies a rest from the NSAIDs.

Acetaminophen (Tylenol) (Paracetamol)

The AAOS guideline recommends acetaminophen for relieving pain and improving function in knee arthritis.

Acetaminophen has a mild analgesic affect but does not have any anti-inflammatory effects.  The side effect of acetaminophen is liver damage if a patient receives more than 4 grams a day.

Oral Steroids

Oral steroids (Prednisone) can alleviate patients’ arthritis pain but also elevate their blood sugars, weaken their immune system, cause weight gain, and increase osteoporosis if taken for prolonged periods of time. Oral steroids should not be considered an appropriate long-term treatment for knee arthritis.

Dietary Supplements

The AAOS guideline analyzed five dietary supplements and stated there is some evidence to recommend the use of turmeric.  The other supplements are harmless but have no evidence to support their use.

  • Turmeric 

  • Ginger Extract

  • Glucosamine

  • Chondroitin

  • Vitamin D

Turmeric (curcuma longa extract) has reasonable evidence to support its use.

  • Wang, 2021 - Turmeric had a similar positive affect as NSAIDs, with fewer adverse events.

  • Srivastava, 2016 - Turmeric decreases inflammatory markers and pain.

You can purchase turmeric on Amazon here.

 

Topical Medications

Voltaren Gel (diclofenac cream)

Voltaren Gel is a topical NSAID that is available over-the-counter in pharmacies, grocery stores, and Amazon. You do not need a prescription. Voltaren is a reasonable option for patients who want to use an NSAID but have stomach ulcers or take a blood thinner.

Capsaicin / Menthol Cream

Capsaicin is the active ingredient in chili powder; it causes vasodilation and makes our skin warm. Menthol causes vasoconstriction and makes our skin cool. There is no evidence that these creams have any lasting effects.  Icy Hot, Bengay, and Biofreeze are examples of these sorts of creams.

Lidocaine patches

Lidocaine patches are a modest way to relieve some minor knee arthritis pain that are available over-the-counter. Stronger lidoderm patches are available with a prescription.

 

Injectable Medications

Cortisone Injections

The AAOS guidelines have moderate support for cortisone injections.

Cortisone refers to five commonly used steroids (Depomedrol, Celestone, Methylprednisolone, Triamcinolone, or Kenalog). Steroids are lipophilic molecules that pass through cell membranes, enter the nucleus of the cell, and shut off the production of inflammatory proteins and cytokines like IL-1, TNF-alpha, etc.

Cortisone can permeate through soft tissue, enter capillaries, and be transported throughout the body. Cortisone works mostly at the injection site but can affect the entire body.

Cortisone injections usually start working within a day and will typically last a few weeks to a few months.

Patients can get cortisone injections every 3 months. Each additional injection usually works about 90% as well as the previous shot, which means most patients will benefit from 5-7 shots in their lifetime.

Diabetics may see a slight elevation in their glucose for a few days.

Some patients report an increase in their appetite after an injection.

Patients with dark skin may occasionally have a slight lightening of their skin color around the injection site.

Insurance does not require prior authorization to get a cortisone injection because it is inexpensive.

Patients must wait three months after a cortisone injection to have knee replacement surgery.

Extended-Release Cortisone Injections

Zilretta is an extended-release cortisone injection. The steroid molecule is encapsulated in a dissolvable microsphere that slowly dissolves over 3–4 months. Zilretta costs about $600-1000 and requires prior authorization from insurance.

Toradol Injections

Toradol is an injectable NSAID that can relieve knee pain for a few days. Dr. Kurtz often includes Toradol along with cortisone when he does a knee injection.

Hyaluronic Acid Injections (Viscosupplementation) (Gel Shots) (Lubrication Shots)

The AAOS guidelines do not recommend hyaluronic acid (HA) injections for knee arthritis because a large number of studies show there is no measurable benefit to HA injections.(Rutjers, 2013) I will provide HA injections to patients who want them but believe any potential benefit from HA is likely a placebo effect.

There are many brand names for hyaluronic acid.

  • Monovisc

  • Orthovisc

  • Synvisc

  • Hyalgen

  • Supratz

  • Eufleuza

In my experience, about a third of patients receive a mild benefit from HA injections, and about two-thirds receive no improvement.  Some patients may have an inflammatory reaction from the injection that makes the knee worse.

Lubrication injections usually require prior authorization and failure of previous treatment (i.e., a cortisone shot) for the insurance company to approve the shot. These shots usually cost around $~1000. Many insurance companies are denying these injections.

Patients who want a lubrication shot should contact Dr. Kurtz and/or Kristie before they come to the clinic.

Platelet-rich plasma (PRP) injection

The AAOS guidelines say platelet-rich plasma (PRP) shots may reduce pain.  PRP injections involve drawing blood out of the patient’s arm, separating the platelets from the red blood cells, and injecting the platelets into the patient’s knee joint.

These platelets are little sacks of chemicals (growth factors and other proteins) that burst open from mechanical trauma when they are injected into a knee joint.  PRP shots will not regrow cartilage. They may relieve pain for 2–3 months, but they don’t work for everyone.

Insurance does not typically cover the cost of these shots. TOA charges patients $~750 for a PRP shot, which covers our cost of the kit used to spin down the platelets.

Injections that don’t work

Stem cell injections do not improve knee arthritis symptoms and cannot grow into cartilage.  Any cells that are injected into the knee will immediately get crushed and spill their intracellular contents into the knee.

The contents of stem cell injections are not regulated by the FDA.  The Federal Trade Commission (FTC) has sued predatory stem cell clinics for making false claims.

Dr. Kurtz does not recommend getting stem cell injections.

 

Exercise

Unsupervised Exercises / Home Exercise Program

Self-exercise can improve patients’ function and reduce pain, even when the patient has significant co-morbidities.(de Rooij, 2016) Tai Chi has been shown to improve balance and proprioception in knee arthritis patients. (Hu, 2020)

Closed-chain exercises (stationary bike, recumbent bike, rowing machine) are preferable to open-chain exercises (jumping, running) for patients with knee arthritis. Closed-chain exercises mean that the patient’s foot stays on the surface during the exercise.

Yoga

Integrated yoga therapy can improve patients’ pain and function. Yoga is generally safe for most patients, but some patients may need to modify some positions and exercises according to their physical condition.

Aquatic Therapy

Aquatic therapy has been shown to improve pain and function in patients with knee arthritis. (Dias, 2017). Aquatic therapy is available at the Vanderbilt Dayani Center, Flow Aquatic, and some YMCAs around Nashville.

Supervised Exercises / Physical Therapy

Supervised exercises and/or physical therapy can help patients strengthen muscles and improve mobility. PT is also helpful to get patients prepared for a knee replacement.

 

Weight Loss

Weight Loss Program

For obese patients, a combination of diet and exercise to achieve weight loss has been shown to be effective at decreasing knee arthritis pain.(Jenkinson, 2009) Other studies showed that weight loss and diet decreased knee arthritis pain. (Christensen, 2015)

Semaglutides (GLP-1, like Oxempic, Wagovy, and Mounjaro) have been shown to help patients lose weight. Please talk to your PCP about these medications.

TOA offers consultations with a dietician for patients who need help with their dietary intake.

 

Medical Equipment

Unloader knee brace

The AAOS guidelines support the use of bracing in motivated patients.  Most patients, including myself, are not compliant with wearing braces. If a patient is highly motivated to wear an unloader brace, I will help the patient get the correct brace.

Palumbo Brace

A palumbo brace (neoprene sleeve) is a simple way to modestly improve patella femoral tracking and symptoms.(Callaghan, 2015)

Heel Cups and New Shoes

Viscoelastic heels cups are a cheap and easy way to add cushion to a patient’s knee joint.

Buying new tennis or running shoes with lots of cushion can allow patients to maintain an active life while living with their knee arthritis.

Canes and Walkers

Canes and walkers have been shown to help with knee arthritis pain for elderly patients. Most importantly, assisted devices can help reduce fall risk.

 

Meniscus tears and arthritis

Meniscus tears are very common.  Many patients get degenerative meniscus tears in their 40's and 50's, arthritis in their 50's and 60's, and then knee replacements in their 60's and 70's.

  • Horga, 2020 - 30% of asymptomatic middle-aged adults have meniscus tears as an incidental finding on an MRI.

  • Englund, 2008 - 60% of patients over 50 with arthritis and knee pain have meniscus tears; 30% with knee pain and no arthritis have meniscus tears; and 25% with no knee pain or arthritis have meniscus tears.

Three studies show that knee arthroscopy for non-obstructive, non-traumatic meniscus tears has the same clinical outcome as just physical therapy.

Dr. Kurtz does not recommend patients with knee arthritis (x-ray evidence and/or subchondral edema on an MRI) get a knee scope unless they have mechanical locking where the knee locks and will not straighten or bend, which is rare.

Knee scopes for degenerative meniscal tears can sometimes provide short-term relief but do not provide any long-term benefit to the knee.  The patient's knee arthritis will continue to progress at the same rate, and the patient will still need a knee replacement at the same point in time, regardless of whether they get a scope or not.

 

When should I do a knee replacement?

There is no harm in procrastinating on getting a knee replacement.  The recovery and outcome of a knee replacement surgery do not change if you delay it.

Before a patient considers getting a knee replacement, I recommend that they should:

  • Attempt most of these non-operative treatments.

  • Adopt some modest activity modifications.

  • Have substantial knee pain that limits their lifestyle.

 

Modifiable Risk Factors

Insurance companies and hospitals usually require patients to correct their modifiable risk factors before they get their knee replacement.  Examples of these modifiable risk factors include:

  • Body Mass Index > 40

  • Current Smoker

  • Diabetic with HgA1C > 8.0

  • Anemia with Hgb < 12.0

If you have any of these issues, please work hard to improve them and discuss them with Dr. Kurtz before you schedule surgery.

 

Dr. Kurtz's clinic locations and times

You can schedule an appointment online using the link below or call our TOA scheduling numbers.

If you need to be seen for an urgent matter and there are no available clinic times, please call Kristie at 615-963-1437 so she can overbook you.

OneCity

8 City Blvd

Nashville, TN 

Monday 1-4

Wednesday 1-4

Directions

Hendersonville

501 Saundersville Rd.
Hendersonville, TN 

Monday 8-11:30

Directions

Brentwood

134 Franklin Rd.
Brentwood, TN

Wednesday 8-11:30

Directions

Lebanon

1035 South Hartmann Dr.
Lebanon, TN

Friday 8-11:30

Directions

 

Contact us

If you have a question about your knee arthritis treatments or suggestions about how we can improve this educational material, please contact us.