Arthritis of the Knee? What Helps and What Doesn’t

(From the American Academy of Orthopaedic Surgeons)
By Roy M. Arnold MD

Arthritis of the knee is very common in the over 40 population. Osteoarthritis occurs from the natural wear-and-tear associated with upright posture and activity. The natural cushion, known as cartilage, between the bones forming the knee joint wears away and the bones begin rubbing together. This results in pain, swelling and difficulty moving. With time, bony overgrowth called osteophytes or bone spurs can develop. An estimated 27 million Americans have knee arthritis.
The American Academy of Orthopaedic Surgeons (www.aaos.org) is the largest professional association of Bone and Joint surgeons in the US and has recently released and exhaustive scientific study of the literature about various treatments for knee arthritis. The actual study contains over 1200 pages of scientific review, but to spare you reading the entire tome, a brief summary is provided below. For clarity the recommendations have been divided into 3 categories; Treatments or techniques that a preponderance of strong scientific evidence demonstrate effectiveness or What Works; Treatments or techniques that a preponderance of scientific evidence doesn’t demonstrate effectiveness or What Doesn’t Work; and finally treatments or techniques for which there is little evidence either for or against effectiveness or Inconclusive.
What Works:
• Exercise – The Academy recommended that patients engage in regular low-impact aerobic exercise and neuromuscular education consistent with national guidelines (150 minutes weekly.) Initially the exercise should be guided by an exercise professional (Physical therapy or athletic trainer.)
• Weight Loss – For those patients over a Body Mass Index of 25, the Academy recommended weight loss.
• Non-Steroidal Anti-Inflammatory Drugs – The Academy recommended for the use of these drugs. This category includes over-the-counter drugs such as ibuprofen and naproxen, and prescription drugs like Celebrex®, indomethacin, diclofenac, or sulindac.
What Doesn’t Work:
• Acupuncture – The Academy issued a strong recommendation against the use of acupuncture based on lack of efficacy in several randomized controlled trials, not on evidence of potential harm.
• Lateral wedge insoles – these are shoe inserts designed to relieve pressure on the knee during walking.
• Glucosamine and Chondroitin – The Academy issued a strong recommendation against based on lack of efficacy not on evidence of potential harm.
• Hyaluronic Acid injections – These drugs are injected directly into the knee joint in hopes that pain relief will result. These drugs are sold under the name of Euflexxa®, Supartz®, Synvisc®, Hyalgan®, and Orthovisc®. These injections are expensive and there was little evidence that they we effective in the Academy’s opinion.
• Needle Lavage – This procedure involves inserting a needle in the knee and washing (lavaging) the joint with sterile saline. The Academy found little evidence to support the use of this procedure.
• Arthroscopy with lavage and/or debridement – This is a surgical procedure in which a scope is inserted in the knee joint, cartilage may be trimmed or shaved and then the joint is irrigated with sterile saline.
• Free floating positioning device – The Academy issued a consensus opinion against the surgical procedure.
Inconclusive: The Academy found little or no evidence to recommend for or against these treatments
• Physical modalities – TENS, electrical stimulation, ultrasound, etc.
• Manual therapies – massage, chiropractic manipulation, or myofascial release.
• Bracing
• Acetominophen, opiates or pain patches.
• Steroid injections.
• Growth factor or platelet-rich plasma injections.
• Partial knee cartilage removal.
• Tibial osteotomy
What most interested me is that many of the more common procedures performed by orthopaedic surgeons like hyaluronic acid injections, other injections, arthroscopy and lavage were not recommended by the Academy. No mention was made of copper bracelets, magnets and other supplements. One can assume there was no published scientific evidence about these treatments.
To this author, it was very encouraging to see a surgical specialty society take a measured, scientific approach to evidence-based medicine and to publish a guideline emphasizing the same without respect to the potential financial impact on its members. A 13 page summary of the recommendations is available online at http://www.aaos.org/research/guidelines/OAKSummaryofRecommendations.pdf.