As a physician, I frequently have the task of delivering news to people. Sometimes the news elicits a positive reaction: “It’s a boy!” “Wooo-hooo!” Sometimes the news elicits a blasé reaction: “Your cholesterol is good.” “Alright.” Sometimes the news elicits a negative reaction: “You’ve had a heart attack.” “Oh no!” Nothing, though, elicits a resigned, I-just-knew-it response quite like when I deliver a diagnosis on knee pain: “You have arthritis.” “Awwwwwww… Crap.”
Like most people, I use the terms “arthritis” and “osteoarthritis” interchangeably, even though it’s not entirely accurate, since other types of arthritis do exist. Osteoarthritis happens when the cartilage, which serves as padding, between two bones deteriorates. When cartilage deteriorates, more force will be transmitted to the bone. This increased force on the bone causes pain. Osteoarthritis can affect nearly any joint in the body, but some joints definitely suffer the effects more often than others. The most commonly affected joints include the shoulders, hands, low back, hips, and knees. I shall focus on the knees for this article.
Osteoarthritis of the knees can cause pain in any part of the joint, but usually the discomfort happens on the front of the knee, and more so in the middle. Knee arthritis tends to cause a deep, aching sort of pain. Many people will feel a grinding sensation in the knee with movement. Climbing stairs, descending stairs, and crouching greatly amplify the pain of knee arthritis. Arthritic knees are stiff first thing in the morning, tend to feel a little better after a bit of moving around, but worse again with prolonged walking or standing. Pain overnight indicates that the osteoarthritis has advanced significantly and that cartilage is pretty much kaput. Those with advanced arthritis frequently have a bow-legged gait.
Some conditions and occupations predispose people to getting knee osteoarthritis. Going up and down ladders produces accelerated wear and tear on knee cartilage; thus, linemen and construction workers have high rates of knee arthritis. Many have a genetic predisposition to osteoarthritis; these people tend to have arthritis at multiple joints. Age, as with nearly all diseases, also plays a role. More years of use equates with more cartilage damage and therefore more arthritis. Being overweight greatly stresses knee cartilage and causes osteoarthritis.
There exists no true cure for knee osteoarthritis. Once a cartilage has been damaged, it will never entirely recover. Arthritis is a progressive disease, which means that someone with arthritis at age 40 will almost definitely have worse arthritis at age 60. This sounds pessimistic, but treatment options do exist which can decrease pain and greatly slow the progression of the disease.
For knee osteoarthritis, weight loss and exercise should be the most important two facets of treatment. Losing even ten pounds can make a huge difference in the level of knee pain someone experiences. If a person takes 3000 steps a day (the average for someone who has an office job), that’s 1500 steps per leg. If that person weighs 300 pounds, their left leg will have carried a total of 450,000 pounds from those steps. If that same person loses ten pounds, their left leg will now have carried 435,000 pounds from those steps. That’s a difference of 15,000 pounds a day, just on the left leg!
Exercise can greatly help knee arthritis, especially long-term. The best exercise for arthritis is swimming laps, but, unless you’re really lucky, you don’t have an Olympic-sized lap pool in your backyard. (If you do have one of these pools, find me and introduce yourself. I would love to mooch off your pool as much as possible and would be happy to re-pay use of said pool with numerous witty and urbane stories which I will tell you while I enjoy a drink at your poolside.) The most practical way for people with knee osteoarthritis to exercise is by walking. A goal of 150 minutes of walking per week should be used. Most people, when they start an exercise regimen, have some worsening of their knee pain initially, but within 2-3 weeks of exercising regularly will note a remarkable improvement in the level of their pain.
As for medications, acetaminophen (that’s generic for tylenol) should be the mainstay of treatment. Acetaminophen is safe, effective, and cheap. The only people who can’t take acetaminophen are those with liver problems or an allergy to the medication. Tylenol comes in three common strengths: 325 mg, 500 mg, and 650 mg. I recommend buying the 500 mg strength and taking two pills up to four times a day. A person could take 1000 mg of acetaminophen four times a day for decades and have really no risk of side effects.
The second-line medication should be a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen. Over-the-counter ibuprofen comes in 200 mg tablets. The maximum dose is 800 mg three times a day. Over-the counter naproxen comes in 220 mg tablets. The maximum dose is 440 mg twice a day. NSAID’s work very well for arthritis pain, but do come with risks of some side effects. Anyone with diabetes, a history of bleeding stomach ulcer, or kidney disease should not take NSAID’s. Prolonged use of NSAID’s can cause permanent kidney damage or bleeding stomach ulcers. For most people, taking an NSAID a couple of days a week for a couple of weeks a year won’t cause any problems. Taking the maximum dose every day for years, however, is not a good idea.
For those who like their medications “natural,” glucosamine chondroitin and SAM-e are two supplements which both have pretty good evidence that they help with osteoarthritis pain. It is difficult to recommend a dosage for these medications, as neither is regulated by the FDA. In general, though, about 1500 mg of glucosamine, 1200 mg of chondroitin, or 400 mg twice a day of SAM-e should do the trick. Glucosamine chondroitin is cheaper, but has less robust evidence of benefit that SAM-e. Those with bipolar disorder or Parkinson’s should not take SAM-e. It is safe to take tylenol, ibuprofen, glucosamine chondroitin, and SAM-e at the same time.
By the time most people have come to see me in the office, they’ve tried several of the above remedies. If exercise, weight loss, and the above medications don’t provide relief of knee osteoarthritis pain, the next step is a steroid injection into the knee. These injections have a wide range of results. At best, the injection can provide up to six months of significant relief. At worst, they don’t help at all. Unfortunately, the only way to know if it will help someone is to try it.
If steroid injections don’t help, the next option is a series of injections of hyaluronic acid into the knee – usually one injection into the knee every week for three weeks. Hyaluronic acid is the lubricating oil of our joints. Once again, the results for this series of injections can range widely, from providing significant relief for some time to providing no relief at all, and the only way to know is to try.
The final option for treatment of knee osteoarthritis is knee replacement. In this surgery, the ends of the two bones in the joint are removed and replaced with metal. This surgery does come with risks and with a several-week-to-several-month recovery time, but most people who have knee replacement end up being extremely happy with the results. Many people ask me when the right time is to have knee replacement surgery. There’s no one-size-fits-all answer to that question, other than to say that if other treatments have failed and the pain is still limiting and significant, then it’s time to consider surgery.
Countless hours of pathophysiology, lots of sleepless nights in the hospital, and numerous medical magazines that I read every month have lead me to give you this advice: if you’ve got arthritis, you’d better get exercising and may need to lose some weight. If that doesn’t help, try some tylenol or ibuprofen. But, you may have heard that from a doctor before.
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As a physician, I frequently have the task of delivering news to people. Sometimes the news elicits a positive reaction: “It’s a boy!” “Wooo-hooo!” Sometimes the news elicits a blasé reaction: “Your cholesterol is good.” “Alright.” Sometimes the news elicits a negative reaction: “You’ve had a heart attack.” “Oh no!” Nothing, though, elicits a resigned, I-just-knew-it response quite like when I deliver a diagnosis on knee pain: “You have arthritis.” “Awwwwwww… Crap.”
Like most people, I use the terms “arthritis” and “osteoarthritis” interchangeably, even though it’s not entirely accurate, since other types of arthritis do exist. Osteoarthritis happens when the cartilage, which serves as padding, between two bones deteriorates. When cartilage deteriorates, more force will be transmitted to the bone. This increased force on the bone causes pain. Osteoarthritis can affect nearly any joint in the body, but some joints definitely suffer the effects more often than others. The most commonly affected joints include the shoulders, hands, low back, hips, and knees. I shall focus on the knees for this article.
Osteoarthritis of the knees can cause pain in any part of the joint, but usually the discomfort happens on the front of the knee, and more so in the middle. Knee arthritis tends to cause a deep, aching sort of pain. Many people will feel a grinding sensation in the knee with movement. Climbing stairs, descending stairs, and crouching greatly amplify the pain of knee arthritis. Arthritic knees are stiff first thing in the morning, tend to feel a little better after a bit of moving around, but worse again with prolonged walking or standing. Pain overnight indicates that the osteoarthritis has advanced significantly and that cartilage is pretty much kaput. Those with advanced arthritis frequently have a bow-legged gait.
Some conditions and occupations predispose people to getting knee osteoarthritis. Going up and down ladders produces accelerated wear and tear on knee cartilage; thus, linemen and construction workers have high rates of knee arthritis. Many have a genetic predisposition to osteoarthritis; these people tend to have arthritis at multiple joints. Age, as with nearly all diseases, also plays a role. More years of use equates with more cartilage damage and therefore more arthritis. Being overweight greatly stresses knee cartilage and causes osteoarthritis.
There exists no true cure for knee osteoarthritis. Once a cartilage has been damaged, it will never entirely recover. Arthritis is a progressive disease, which means that someone with arthritis at age 40 will almost definitely have worse arthritis at age 60. This sounds pessimistic, but treatment options do exist which can decrease pain and greatly slow the progression of the disease.
For knee osteoarthritis, weight loss and exercise should be the most important two facets of treatment. Losing even ten pounds can make a huge difference in the level of knee pain someone experiences. If a person takes 3000 steps a day (the average for someone who has an office job), that’s 1500 steps per leg. If that person weighs 300 pounds, their left leg will have carried a total of 450,000 pounds from those steps. If that same person loses ten pounds, their left leg will now have carried 435,000 pounds from those steps. That’s a difference of 15,000 pounds a day, just on the left leg!
Exercise can greatly help knee arthritis, especially long-term. The best exercise for arthritis is swimming laps, but, unless you’re really lucky, you don’t have an Olympic-sized lap pool in your backyard. (If you do have one of these pools, find me and introduce yourself. I would love to mooch off your pool as much as possible and would be happy to re-pay use of said pool with numerous witty and urbane stories which I will tell you while I enjoy a drink at your poolside.) The most practical way for people with knee osteoarthritis to exercise is by walking. A goal of 150 minutes of walking per week should be used. Most people, when they start an exercise regimen, have some worsening of their knee pain initially, but within 2-3 weeks of exercising regularly will note a remarkable improvement in the level of their pain.
As for medications, acetaminophen (that’s generic for tylenol) should be the mainstay of treatment. Acetaminophen is safe, effective, and cheap. The only people who can’t take acetaminophen are those with liver problems or an allergy to the medication. Tylenol comes in three common strengths: 325 mg, 500 mg, and 650 mg. I recommend buying the 500 mg strength and taking two pills up to four times a day. A person could take 1000 mg of acetaminophen four times a day for decades and have really no risk of side effects.
The second-line medication should be a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen. Over-the-counter ibuprofen comes in 200 mg tablets. The maximum dose is 800 mg three times a day. Over-the counter naproxen comes in 220 mg tablets. The maximum dose is 440 mg twice a day. NSAID’s work very well for arthritis pain, but do come with risks of some side effects. Anyone with diabetes, a history of bleeding stomach ulcer, or kidney disease should not take NSAID’s. Prolonged use of NSAID’s can cause permanent kidney damage or bleeding stomach ulcers. For most people, taking an NSAID a couple of days a week for a couple of weeks a year won’t cause any problems. Taking the maximum dose every day for years, however, is not a good idea.
For those who like their medications “natural,” glucosamine chondroitin and SAM-e are two supplements which both have pretty good evidence that they help with osteoarthritis pain. It is difficult to recommend a dosage for these medications, as neither is regulated by the FDA. In general, though, about 1500 mg of glucosamine, 1200 mg of chondroitin, or 400 mg twice a day of SAM-e should do the trick. Glucosamine chondroitin is cheaper, but has less robust evidence of benefit that SAM-e. Those with bipolar disorder or Parkinson’s should not take SAM-e. It is safe to take tylenol, ibuprofen, glucosamine chondroitin, and SAM-e at the same time.
By the time most people have come to see me in the office, they’ve tried several of the above remedies. If exercise, weight loss, and the above medications don’t provide relief of knee osteoarthritis pain, the next step is a steroid injection into the knee. These injections have a wide range of results. At best, the injection can provide up to six months of significant relief. At worst, they don’t help at all. Unfortunately, the only way to know if it will help someone is to try it.
If steroid injections don’t help, the next option is a series of injections of hyaluronic acid into the knee – usually one injection into the knee every week for three weeks. Hyaluronic acid is the lubricating oil of our joints. Once again, the results for this series of injections can range widely, from providing significant relief for some time to providing no relief at all, and the only way to know is to try.
The final option for treatment of knee osteoarthritis is knee replacement. In this surgery, the ends of the two bones in the joint are removed and replaced with metal. This surgery does come with risks and with a several-week-to-several-month recovery time, but most people who have knee replacement end up being extremely happy with the results. Many people ask me when the right time is to have knee replacement surgery. There’s no one-size-fits-all answer to that question, other than to say that if other treatments have failed and the pain is still limiting and significant, then it’s time to consider surgery.
Countless hours of pathophysiology, lots of sleepless nights in the hospital, and numerous medical magazines that I read every month have lead me to give you this advice: if you’ve got arthritis, you’d better get exercising and may need to lose some weight. If that doesn’t help, try some tylenol or ibuprofen. But, you may have heard that from a doctor before.
