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Method Health
15 hours ago14 min read

Knee Osteoarthritis (OA)

Knee OA without symptoms or suffering is common with aging, and can be thought of as grey hair and wrinkles of the knee.

How common is knee OA?

It is the most common cause of knee joint pain or stiffness in people over 45 years old, and the knee is the most common site for symptomatic OA.


●    Clues or common symptoms? Most receive the initially scary diagnosis of knee OA after experiencing a knee OA “flare-up.” A knee OA flare-up is characterised by pain, perceived stiffness, or random knee buckling plus or minus swelling around the knee. Pain can spread around the knee and change in location without a “textbook” pattern, which can be very confusing for those trying to understand their condition or only blame the knee cartilage. Knee OA is not a short-term injury, although it is often perceived so when one has a flare-up. Knee OA flare-ups are often associated with meniscus changes mistakenly considered separate. Other conditions with similar presenting symptoms like swelling and pain include a fracture or ligament sprain associated with high-energy trauma, tendon pain, or other metabolic joint conditions like gout or joint infection. These can be ruled out with some confidence after a good conversation with an evidence-based health professional. Despite popular belief that it is helpful, imaging is unnecessary for diagnosing knee OA pain when we are confident other conditions requiring medical care are absent. Imaging is not recommended even for reassurance unless predicted imaging results are likely to change management, for example, we think you might have a significant ligament sprain, bone injury or gout. Should I get an MRI for my knee osteoarthritis? with Dr James Linklater (youtube.com)


What is wrong? 

Knee OA is a whole joint condition affected by your whole body health. Radiographic OA is a structural change with no perceived symptoms, seen on imaging of the knee joint. It occurs in most people with healthy aging and is analogous to skin calluses, grey hair, and wrinkles. Symptomatic OA is when these imaging-related factors are present AND the knee joint is painful and swollen (symptomatic), also called a flare-up. Due to interacting risk factors, predisposition to knee OA (or OA of any joint) and its associated flare-ups develop over decades. Cartilage is affected, but pain and swelling symptoms are also significantly driven by inflammation of the joint capsule, called the joint synovium, muscle, ligaments, and knee joint bones. In particular, joint synovium can develop a lower threshold to trigger swelling during a flare-up. The whole joint is grumpy rather than just having injured cartilage. So, be aware of the difference between having radiographic OA (imaging changes most people will develop with aging without pain) or symptomatic OA (symptoms of knee OA with or without associated imaging changes). 


●    Why me/what are risk factors? Trauma to the knee, either from joint injury plus or minus joint surgery (like an ACL injury +/- repair or meniscectomy), and genetic factors (so you could blame your parent/s) can increase the risk of lifelong inflammation and an increased predisposition to earlier radiographic and symptomatic OA. As well, modifiable lifestyle factors like increased body fat, low weekly physical activity, and poor coping with mental and social stress can increase the risk of symptomatic OA and regular knee flare-ups. Predictably, joint flare-ups (when most get concerned and seek healthcare) occur when modifiable OA risk factors are increased suddenly across days to weeks, which decreases the body's threshold for maintaining a “quiet happy knee.” Think of sudden increased use of your lower limbs (especially after prolonged underuse) combined with a stressful period. Stress reduces your ability to tolerate the use of your joints or recover from increased use. Days, weeks, or months of periods of high mental stress, worsening sleep, or increased weight gain, plus or minus a sudden increase in knee movement, often are reported in discussion with a client, to precede a joint flare-up. Joint flare-ups are not caused by increased joint damage but by increased activity of the joint synovium, producing lots of immune cells that aggravate the nervous system of your knee. 


●    What can I do about it? For your reassurance, symptomatic OA is not as inevitable as once thought, and frequent flare-ups or progression of knee OA symptoms and whole joint changes are not inevitable. Reduce lifelong inflammation\, and knee OA will have minimal symptoms though you still might have pain-free radiographic OA. What was once believed to be a “wear and tear cartilage” and “bone on bone” condition is now known as a “wear and repair” condition. Symptomatic OA development risk is reducible. OA does not progress unless lifestyle factors (often influenced by beliefs in old OA myths) drive people to move less and stress more. The aims of management are 1) education, 2) weight management, and 3) exercise medicine, which are combined to be offered to those with OA as “lifestyle medicine.” Lifestyle medicine is undervalued due to old beliefs, poor health professional education, and a busy healthcare system. Medication, injections, and surgery are offered too soon in our culture and often with the promise of unrealistic long-term symptom relief. These interventions should only be offered if symptomatic OA reduces your quality of life and PT management has not been helpful for many months to years.

○       Education for knee OA involves seeking and receiving evidence-based updated resources and coaching about your OA flare-up risk factors, accepting your considerable control and the uncertainty you still have for preventing all flare-ups. This usually means modifying beliefs and behaviour away from “the body is a machine and joints wear and tear like old parts” towards “the body is a living, adaptable complex ecosystem that is strong even when in pain, can tolerate lots of stress and become stronger over time without needing to reverse all the effects of aging.”

○    Weight management involves seeking help from a dietician or high-quality internet nutritional resources to lose weight and improve nutritional quality, essential in improving joint health. You do not need to be overweight or lose weight for nutritional improvement or exercise to be helpful. Still, it will relieve the body of persistent inflammation inherent in the chemicals released each minute from body fat. Focus on achieving an optimal body fat percentage (10-25% males or 15-30% females), waist circumference (110 cm males or 95 cm females), or BMI (20-25 for both males and females) improvements rather than your “preferred bodyweight.” Any weight loss is better than none. If you feel you or have been told are underweight while being given the diagnosis of knee OA, gaining lean muscle mass with exercise, especially strength training around the knee joint, will improve your lean mass and therefore the composition of your “body weight” and the health of your knee joint.

○    Exercise medicine is strongly recommended for everyone, with or without knee OA. Most do less than and should increase their weekly physical activity to meet and exceed the Australian Physical Activity Guidelines. Most will benefit from adding lower-body aerobic and strength exercises (think eating apples and oranges is healthier than eating one fruit only) to improve tolerance to the activities impacted by knee pain. Sometimes, even upper-body exercise is helpful for lower-body OA symptoms. Pain during knee activity is safe and encouraged if the pain is tolerable and the activity is of a dosage at or below what you have done before. Persist at tolerable doses and your tolerance to exercise and your fun-valued activities should increase. Sometimes, a knee brace or taping can be helpful while you are improving tolerance to knee-bending tasks again and can be weaned off over time. Massage and other forms of manual therapy may have small additive benefits to help you ensure the completion of weekly exercise (lifestyle medicine).


Other management options: Injections are decreasingly recommended for knee joint pain based on recent research updates. Most biologics (Platelet-rich plasma or hyaluronic acid) are not more effective than placebo. Corticosteroid injection or joint aspiration (removes flare-up fluid) may provide up to eight weeks of potential pain or swelling induced discomfort relief, a time period that should be used to provide a window of opportunity to benefit from the joint health-promoting effects of 8 weeks of lifestyle medicine habits. Surgery should only be sought when lifestyle medicine has been attempted for multiple months to years, but symptoms have become intolerable during valued activities. Surgery is not inevitable for everyone with knee OA as, statistically, it is needed for less than 20% of those with knee OA (but is offered a lot more than that due to old-fashioned beliefs). A total joint replacement for knee OA has never been shown to be more effective for symptomatic knee OA than a placebo/sham surgery but can be very helpful for those with persistent symptoms reducing quality of life! Knee braces can be helpful for some to complete more of their valued active activities. 


Busting Myths and Common OA beliefs


 

●    How long will it take? If you are optimistic, have clear expectations and education about what knee OA pain and flare-ups mean (more knee pain does not equal more knee damage), and follow realistic, up-to-date lifestyle, weight management and exercise advice, many can feel much better by three months of lifestyle medicine consultation. Sometimes, it takes more than six months to feel better. Often, people on the waitlist for joint replacement might cancel their surgery due to feeling satisfied with their knee health while waiting for their surgery date. Don’t be too concerned; if your symptoms last longer than this time frame. This does not mean you will not improve when following good advice. Just keep doing the things that are helpful for your knee health and immune system, like improving your general health (sleep, balanced diet, physical activity, stress coping). You can live well with knee OA. 


What can Physiotherapy or Exercise Physiology at MH offer?

●    We can offer individual advice on lifestyle medicine to help you modify physical activities to tolerate keeping up with life with knee pain. Knee OA pain or the perceived unmodifiable risk of knee flare-ups or joint surgery should not stop you from doing the things you love, and these concerns might contribute to worsening joint health anyway. 

●    We can be your support crew to encourage lifestyle changes that can improve your general health, like coaching around sleep and guiding you through ways to reduce stress or adding things to your life to better cope with stress or a knee OA flare-up.

●    If you have had persistent knee pain and are very confused about why you still have it, we can help you make sense of the pain, highlight areas of management to prioritise or be more optimistic about, and give you individual guidance to assist in managing and resolving it.

●    Physiotherapy consultation can help suggest a confident diagnosis of knee OA, rather then other time and medical cost wasting “red herrings” while both exercise physiologists and physiotherapists can offer high-quality exercise-based management to live well with Knee OA.

●    We can help you reduce your perceived need for injections or joint surgery if you do not wish to receive these management options or increase your realistic evidence informed expectations of how injections or surgery might help you. We can also help support your physical and mental preparation and return to your valued activities with less pain and discomfort if you elect for joint surgery.

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