Knee Osteoarthritis- The facts you need to know.

Most people will know someone who suffers from knee osteoarthritis (OA), but for those with the condition life can be one painful journey that can have a significant impact on your day to day activities. Many people believe that if you have knee arthritis your pain will never improve and will only get worse until you need a joint replacement. Well, I am here to set the record straight. What works, what doesn’t when it comes to managing knee arthritis- you might be surprised with what you read.

Osteoarthritis is a chronic disorder where there is breakdown of the cartilage and abnormal changes in the structures of joints. It can affect any joint in the body for example knees, hips and hands. It is the most common chronic lifestyle disease with one in eight people affected. It is also the second most common cause of early retirement due to ill health, and is estimated to cost the Australian health system over $6 billion a year.

So, what are the real facts about knee osteoarthritis?

There has been a huge amount of research in recent years into the causes of OA as well as the best ways to effectively manage it. What we used to know about knee arthritis and the ways we used to treat it are very different to the modern, evidence-based approaches used today. We used to think of it as a wear and tear disease where the more the joints were used, the more wearing away of the cartilage there was.

This is what the recent research has discovered:

Osteoarthritis is not really a wear and tear disease. The reason OA develops is due to an imbalance in the cartilage breakdown and synthesis. When the rate of breakdown is greater than the synthesis thinning of cartilage surface occurs. Other changes occur around the joint including bone and muscle changes, inflammation, and cyst formation.
There is no single cause of knee OA. However, there are a host of biological and mechanical factors that when combined lead to the development of arthritis.

factors OA

A diagnosis is best obtained by a professional who conducts a good history and physical examination. X-rays and other scans are most often not necessary except if the cause of the symptoms is uncertain, or to rule out other conditions. The structural changes seen on x-rays do not correspond well to pain or clinical presentation. In fact, many of the structural changes seen on x-ray and MRI are also found commonly in people with NO symptoms. We see these as age related changes rather than using them as a diagnostic tool. They can’t show pain or severity of the condition.

diagnosis

Most people diagnosed with knee OA will not ultimately require joint replacement.
The first line of treatment is focussed on managing the condition rather than finding a cure.
Research is clear that consistently loading your knee with activities like weights or running actually produces healthier knees.

Other research has found that runners do not have more knee OA and actually suffer much less knee pain than the general population (G Ho et al 2018).

What are the myths and misconceptions with knee OA?

Here are some common myths that have been shown to be untrue.

Knee OA is “bone on bone”.
Knee OA is caused by “wear and tear”.
Exercise and loading the knee joint will cause further damage.
Pain due to knee OA will inevitably get worse over time.
Physiotherapy, exercise and physical activity will increase knee pain.
Experimental and/or surgical treatments will replace lost cartilage and cure knee pain.
Knee joint replacement is inevitable.

So why do I have knee pain and where does it come from?

Arthritis pain is often quite complicated. It is not possible to say that the pain is coming from the areas of reduced cartilage thickness or exposed bone. In reality, pain is experienced in varying severity by different people with similar levels of degeneration, and can also increase and decrease over time.

There are many different factors that can contribute to the pain experience. Many of these factors increase the overall pain experience but some can reduce the levels of pain felt.

Stress and anxiety can have a compounding effect on pain
Your past experiences and beliefs about the condition can impact the pain
Sleep and diet can affect the pain experienced in your knees
Your weight can have a substantial impact on your pain. Studies have shown that a small amount of weight loss can reduce pain levels by a significant amount.
And the amount that you do, and the strength of your knees can influence the pain.

A little on load tolerance.

If the activity you do (let’s say walking 1km) causes the knee pain to increase, it means that the tolerance or resilience in your knee cannot cope with the demand. In other words, your knees aren’t strong enough to cope with the demands (or loads) placed on them. So you have 2 options; you can either reduce the amount you walk so the pain doesn’t increase (maybe to ½ km), or alternatively you can increase the strength and resilience in your knees so you can cope easily with 1, 2 or more kms.

But this is not easy because the Catch 22 is that the more I exercise the more pain I get, but I need to exercise to reduce the pain that I experience. The trick is to do the right type of exercise at the right level to “trick” the knees to get stronger without them experiencing a flare up in pain. It is important to note that many of the exercises needed to build this tolerance require a bit of pain to be effective, but the key is to have that pain settle relatively quickly after the exercise. We also need to understand that this pain is just a hurt and is not really harming the knee.

So, the best way is to start with a graded knee strength and stability exercise program to slowly build up a buffer so you can handle all the demands that you place on the knees throughout the day. Over time as the knee strength increases so too does the activity levels that you can tolerate. Soon enough you should be able to cope with many more activities without any exacerbation in pain. Whilst it can be that simple, there are often many more factors involved that must be taken into consideration- things like biomechanics, co-morbidities like weight, and the psychological impacts of pain. The best way to achieve a great outcome is to have a physio who is trained in managing arthritis pain to be able to guide you through the process of building your load tolerance.

What else is there?

There is also an enormous amount of evidence to show that education about arthritis pain and the way it impacts us as a person can have a significant positive impact. Just like you have been reading here, the research says that the more you understand about pain and managing pain, the better the outcome.

Unfortunately this not what we often see. Because of past beliefs and old information about managing knee arthritis, poor management of arthritis pain is still occurring. There is no evidence to suggest that a cure for osteoarthritis is imminent. Modern treatment is about managing the condition, not fixing it. Relying on medication, having arthroscopic surgery, the latest injections or protecting the knees from further damage will ultimately lead to poor outcomes and most likely a worsening of the pain.

In fact, one study of sham knee arthroscopes by Moseley in 2002 showed that for arthritic knee pain surgery was no more effective than placebo surgery.

So what should you do?

The best evidence we have to manage knee arthritis is this:

Seek help and guidance from a physiotherapist who has been trained in the modern, evidence-based approach to managing osteoarthritis.
Have a good understanding of what OA is and how it is best managed. Education is essential. Work out all the factors that contribute to the pan experience. Understand that it is a multifaceted approach and there are no quick fixes.
Start a strength and load tolerance program, this will ultimately give you the best chance of reducing the pain long term. It really is about developing the tolerance to be able to do the things you want and need to do.

triangle treatment

Develop new activities and interests that encourage movement.
Consider your weight, your diet and your sleep; all will impact your pain.
If you have x-rays or other scans, that is fine but understand that they don’t give a good picture of what is happening with your knee and your pain.

If you would like to learn more feel free to reach out to one of our physios who can help you understand what your options are for you to be able to manage your knee osteoarthritis, and how we can help guide you through your management.

Our GLA:D Program for managing knee and hip arthritis

The GLA:D Australia program is an evidence-based program aimed at improving the quality of care of knee and hip osteoarthritis (OA) in clinical practice.

The aims of the program are to educate participants about evidence-based management for osteoarthritis, to exercise in order to develop strength, increase function and reduce pain, and to promote self-management. Ultimately to prevent unnecessary and costly surgery.

The program consists of:

An initial physiotherapy assessment
Two education sessions on to teach you about OA risk factors for OA, and management strategies including exercise
12 sessions of supervised and individualised strength and neuromuscular exercise delivered by physiotherapists specifically trained in the program.

physio can help OA