Posts in knee arthritis
Arthroscopic Surgery for Knee Pain

Last year over 500,000 thousand arthroscopic knee surgeries (scopes) were performed in the Unites States making it one of the most common orthopedic surgical procedures.  In a previous post we highlighted some of the evidence behind this surgery showing it is not superior to a sham or placebo surgery for degenerative meniscal tears.  In addition, many literature reviews and analyses have shown the procedure offers little to benefit to patients with knee pain (Thorlund et al. BMJ. 2015).  

A recent article in the British Medical Journal compared Physical Therapy exercises to surgery for middle aged patients with degenerative medial meniscal tears (Kise et al. 2016).  The authors found no difference in self reported knee function at long term follow up, but reported greater strength and muscle performance in the exercise group.  Patients with knee pain are encouraged to utilize Physical Therapy over surgery for painful knee conditions.   

Hyaluronic Acid vs. Corticosteroid for Knee Osteoarthritis

Knee Osteoarthritis is a common condition affecting many middle aged adults which leads to pain, loss of range of motion, and decreased function.  Physical Therapy remains the primary choice for conservative treatment, but often these treatments are combined with injections to the knee joint.  Corticosteroids are an inexpensive injection designed to reduce pain and inflammation in the knee, but Hyaluronic Acid injections such as Synvisc are also on the rise.  These injections claim to cushion and lubricate the knee joint leading to reduced pain and improved function.  One downside of these injections is their cost ($250-$1000 per injection) which is often not covered by insurance.  In addition, the research on these injections has been compared to saline (placebo) injections instead of a head to head comparison with the corticosteroid.

Recently an article in the Journal of Bone and Joint Surgery examined the impact of a single corticosteroid or hyaluronic acid injection on 99 patients with knee osteoarthritis (Tammachote et al. 2016).  Patients were randomized to receive one of the two injections then followed over 6 months.  As you can see from the graph above both groups demonstrated similar outcomes in pain, function, and range of motion at 6 months.  Differences were noted in the short term with decreased pain and improved function noted in the first two weeks in the patients receiving the corticosteroid.  The authors called into question the cost of these expensive injections compared to the less expensive corticosteroid.  

Does Physical Activity Improve after a Total Knee or Hip Replacement?

Total knee and hip replacements are among the fastest growing surgeries in our country.  Physical Therapy remains the first line treatment for patients with knee and hip arthritis, but in patients with severe osteoarthritic pain and loss of function joint replacement remains a good surgical option.  In prior research among patients undergoing these procedures there is often a disconnect between subjective reporting of pain and function and the objective testing of a patient's function.  For example, a patient may report great outcomes and an ability to walk long distances without fatigue or pain, but objective testing in Physical Therapy often reveals residual endurance, strength, and balance impairments.  

In addition to severe pain, one of the most important indications for a total joint procedure is loss of function.   After the surgery patients are expected to increase their activity levels due to reduced pain, but new research is questioning this assumption.  A recent review article in the Journal of Orthopedic and Sports Physical Therapy examined if physical activity levels increased after these procedures (Arnold et al. 2016).  Authors reviewed the available data and found 8 studies of 373 patients who underwent a total joint replacement.  

These studies objectively tracked a patients physical activity levels up to 1 year after the procedure to see if levels had increased compared to pre operative levels.  The authors reported negligible improvements at 6 months and limited evidence to support increases in activity levels at 1 year.  At one year, patients with total joint replacements were significantly less active than their peers.  This study indicates the importance of post operative Physical Therapy to effectively improve strength, endurance, and balance allowing patients to resume an active lifestyle.  

Injections for Knee Osteoarthritis

Knee osteoarthritis is a common condition in aging adults leading to pain and reduced performance of daily and recreational activities.  Manual therapy and exercise remain a hallmark of conservative care for this condition and have been shown to delay or prevent the need for a total knee replacement.  In addition to exercise, corticosteroid injections are often proposed to patients in order to reduce pain and improve patient participation.  A recent study in the Journal of the American Medical Association examined the impact of these injections in patients with knee arthritis.

Henriksen and colleagues studied 100 patients and randomized them to either a corticosteroid injection or a placebo injection prior to undergoing Physical Therapy 3 days a week for 12 weeks.  These patients all had evidence of knee arthritis on x ray and reported pain with daily activities including walking.  All patients improved through the course of the study, but no significant differences were noted at 2, 14, or 26 weeks between the group receiving a corticosteroid injection or a placebo.   The authors concluded there was no additional clinical benefit of a steroid injection and Physical Therapy compared to Physical Therapy alone.  Thus, Physical Therapy was the main reason for the patient's improvement.   

Patients with knee osteoarthritis are encouraged to seek out a local Physical Therapist to implement an effective rehabilitation program.  

Evidence Does Not Support Knee Surgery for Meniscal Tears

Tears in the meniscus, cartilage within our knees, can occur due to injury or degeneration attributed to the aging process.  The latter is a much more frequent scenario and often these tears are found on MRIs of patients without knee pain.  These false positive results cast doubt on the direct correlation between a picture of your knee and the symptoms you are experiencing. Thus, meniscal tears are found in patients without pain and those with pain can have a negative image.  Unfortunately, arthroscopic surgery for these age related tears is on the rise with 700,000 procedures performed in the United States each year (Cullen et al. 2009).  Interestingly, a previous randomized controlled trial in the New England Journal of Medicine found no difference in patient outcomes between this meniscal surgery and a sham surgery (Sihvonen et al. 2013).  

In the study, 70 patients were randomized to a partial menisectomy (removal of the meniscus) and 76 were randomized to a sham surgery (Sihvonen et al. 2016).  In the article published in the Annals of Internal Medicine the authors reported close to half of the patients in either group reported mechanical symptoms such as locking or catching prior to surgery.  Surprisingly, no differences were noted between the surgery and sham surgery for relief of pain or mechanical symptoms.  The authors concluded, "resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking".

Patients with meniscal tears are advised to work with a local Physical Therapist on an cost and clinically effective treatment plan before considering any surgical procedure.  

Resistance Training the Aging Adult and Injury Prevention

There are few treatments more effective for the prevention and treatment of injuries and musculoskeletal conditions than resistance training.  Unfortunately, many Americans are not performing enough strengthening to prevent the loss of muscle mass (sarcopenia) which begins to occur in the 3rd decade of life.  After age 30 we begin to demonstrate a progressive loss of muscle mass, strength, and endurance due to the aging process.  Thankfully, this loss can be attenuated with strength training, but not solely aerobic and endurance training (Klitgaard et al. 1990).  This loss of strength becomes a risk factor for many health conditions including low back pain and knee osteoarthritis.  

It is important to note age does not seem to influence an individuals ability to perform strength training exercise.  A review article reported an average strength increase of 25-33% in older adults who began a strength training program (Peterson et al. 2010).  Participants performed 2-3 sets of 8-10 repetitions per exercise targeting major muscle groups 2 to 3 days per week.  These programs have also been shown to improve an adult's quality of life and prevent conditions such as osteoporosis, knee osteoarthritis and back pain.  

It is never too late to begin an exercise program and adults are encourage to speak with a local Physical Therapist to design a safe and effective exercise program to improve their quality of life and athletic performance.