Knee problems can happen to anyone at any age. This vulnerable joint is essential to many of our day-to-day activities, such as walking, kneeling, and bending, and must hold up to a great deal of stress from high impact activities like jumping and jogging.
Knee pain caused by injury, inflammation, or arthritis can greatly impact your activity level and quality of life, but there is good news.
According to The Christ Hospital orthopedic surgeons Todd C. Kelley, MD, and Michael Palmer, MD, and senior physical therapist Andrew Naylor, DPT, SCS, there is hope and many treatment options for reducing or eliminating pain. Here’s what you need to know:
1. We all get wear and tear on our knee joints.
Knee pain can be caused by an injury such as a fracture, or tear of the cartilage, ligaments, and tendons, or by inflammation. It can sometimes be referred pain from a back or hip injury, to where nothing is wrong with the knee itself. Arthritis is a very common cause of knee pain.
“There are many forms of arthritis,” says Dr. Kelley, “There’s rheumatoid arthritis where your body is attacking your own joints. There's inflammatory arthritis such as gout. There's post traumatic arthritis that can follow a break in your knee or the bones around your knee. But osteoarthritis is the most common kind of arthritis, and that’s general wear and tear of the cartilage.”
“Healthy cartilage is bright, white, smooth, and shiny, like a pool cue ball. As we age, that cartilage gets thinner and thinner” continues Dr. Kelley. “We start seeing little dents and little divots in the cartilage that could be from an injury you forgot you even had, like jumping out of a tree as a child. Those little dents and divots become potholes, and then those potholes become more bone on bone.”
Genetics may play a role in who gets arthritis of the knee. “Sometimes it’s just what Mom and Dad gave you,” says Dr. Kelley.
Weight is a key component, too. “Three times your body weight goes through your knees with every step you take,” adds Kelley. So carrying an extra 5 or 10 pounds really adds up, causing the cartilage to wear out faster.
But just because you have wear and tear in your knee joint, that doesn't mean it's going to cause pain, or significant pain, or stop you from doing the things that you're enjoying.
2. Surgery isn’t always the answer. Effective non-surgical treatments are available.
There are many non-surgical strategies for addressing knee pain according to senior physical therapist Andrew. These include lifestyle changes, changing your activities, exercising and weight loss, physical therapy, and using aids like braces or canes, and supportive footwear.
Ice can also be helpful in reducing inflammation and pain, as can topical pain creams, or anti-inflammatories such Advil, Aleve, or Tylenol. Some find acupuncture and supplements like glucosamine and chondroitin help.
“While you may not be able to control the genetic component of osteoarthritis, you can make lifestyle changes that can have great impact, like weight control,” says Andrew. “And if you're a smoker, stop smoking. Smoking limits your body's ability to heal, both before surgery and after surgery.”
Physical therapy and exercise can build strength and improve balance. It’s especially important to focus on strengthening your quadriceps and glutes to protect the knee joint. Changing your activities from high impact to low impact is also important, like trying walking or cycling instead of running, or changing your activity frequency, such as running three days a week instead of five.
“If you still are a candidate for surgery, research shows that a good preoperative exercise program can lead to better surgical outcomes,” says Andrew. “When you are scheduled to have a joint replacement at The Christ Hospital, you are referred into our physical therapy program and begin sessions prior to your scheduled surgery date.”
Interventional non-surgical treatments:
Injections: “There are two different types of injections that we typically use,” says Dr. Kelley. One is cortisone, which is a steroid and a powerful pain medicine that reduces inflammation. It takes about two minutes to inject in the office to help with the pain and the swelling. We try to space out those injections, typically about three-month intervals is safe.
“I’ve had people getting cortisone injections for about 12 years. They come every three to four months for a cortisone injection, and it keeps them doing things that they enjoy. If we can find something that keeps you comfortable and out of the operating room, that's fine.
“The other type of injection are gel injections. You may see these advertised on TV a bit more now,” continues Dr. Kelley.
“There's a bit of myth around the gel injections because of these TV ads. They show the medicine going in and a cushion or some glowing fluid that is somehow doing something inside of the knee. But it's not a pain medicine, it's a lubricant. It's trying to lubricate the cartilage that you have.
“When you get to the point where you're bone on bone and you don't have much cartilage left, it's hard for that medication to do much of anything. In terms of injection predictability, the cortisone of the steroid injection tends to be more predictable for people than the gel injections.”
Stem cells or PRP (platelet rich plasma): To get stem cells, your own blood is drawn, spun down and then injected back into the knee. “There's not great evidence behind this right now,” says Dr. Kelley. “It is also not covered by insurance, and tends to be expensive, so I don’t recommend it.”
“A last resort might be trying a nerve block with some of our anesthesia colleagues. They're very good at finding the nerves that come around the knee and isolating them to block the pain.”
3. Myths about knee replacement surgery and knowing when you're a candidate
Myths about surgery
There's a lot of fear and anxiety about knee replacement, much of it fueled by myth. People think they are too young – or too old. Some think knee implants don't last. Others believe the surgery and its recovery are too painful.
“First, being young or being more senior doesn't exclude you from getting a knee replacement," says Dr. Palmer. “We consider age, but more in the context of how long the implant will last, or your risk for falling, as well as your heart health and history of stroke."
The other misconception is that knee replacements don't last long. “We track implants and patients going back 15 to 20 years," continues Dr. Palmer. “You have about a 1% rate of the implant failing for each year that implant is in your body, so at 20 years, 80% of people still have a very well-functioning knee implant. That's actually good longevity."
Many people believe the surgery and the recovery are just too painful. “It is a difficult recovery. A lot of times it is underestimated," says Dr. Palmer, “but there are more modern pain management techniques that we are using to keep you more comfortable and to avoid the use of narcotics. We use multimodal analgesics, which means that we're hitting those pain receptors from all sorts of different medications and injections around the knee at the time of surgery to block the pain."
“Two to three weeks after surgery, most people are just taking an anti-inflammatory and Tylenol."
Are You a Candidate?
“How much pain are you in?" asks Dr. Palmer. “How much does your knee pain interfere with your ability to do things in your everyday life? Go up and down stairs, get in and out of your car, walk around the grocery store, play with your kids, play with your grandkids, exercise? Can you play golf? Can you play tennis? Can you walk?"
The goals of knee replacement surgery are to decrease pain, improve function, potentially straighten your leg if you have a deformity and overall, to improve your quality of life, continues Dr. Palmer.
“Understanding what level of function you're at and what activities you want to get back to doing that you can't do right now because of your knee," says Dr. Palmer, “helps us understand your expectations and how your expectations align with ours. We try to make sure that those align because that will help us have a successful outcome."
4. Differences between partial knee replacement and total knee replacement
When non-surgical options have been exhausted, and knee pain is interfering with your activities of daily living, a knee replacement can replace damaged surfaces, help relieve pain and restore mobility.
“In general, we break knee replacement down into partial versus total knee replacements,” continues Dr. Palmer. “About 5 to 10 percent of patients qualify for a partial knee replacement, where we resurface or replace one part of the knee. The benefit of a partial knee replacement is you replace the part that is worn out and you save the rest of your knee that’s not damaged. This can be less invasive with a quicker recovery.”
“The risks of partial knee replacement are that the arthritis will continue to progress, eventually leading to a total knee replacement.’
Up to three bone surfaces may be replaced during a total knee replacement—the lower end of the thighbone (femur), the top surface of the shinbone (tibia) and the back surface of the kneecap (patella). Damaged bone and cartilage are then replaced with parts made of metal and plastic.
“Total knee replacements are one of our most reliable and most common surgeries, with very reproducible and excellent outcomes. This is what the majority of patients have, with a very high satisfaction rate.”
5. Life Beyond Treatment – From “Why Did I Do This” to “I’m So Glad I Did”
“Most knee replacements can now be done as outpatient surgery,” says Dr. Palmer, “meaning you get to come in and go home the same day and recover in your own home. That has significantly improved rates of infection and reduced complications because you're recovering at home and in your comfortable environment. That’s been a huge game changer for us and our patients.”
“There's a honeymoon period where the patient is feeling pretty good based on the anesthesia they had and the amount of pain medication that the docs can put in the knee during surgery,” says Andrew. “Some say I feel great, I'm hardly taking my pain meds and I say, please take your pain medication as prescribed to make sure that you don’t get behind the pain, as they say. We want people to take their medication as prescribed and do general movement exercises to prevent blood clots in the 1st 24 to 48 hours at home.”
“But you don’t just stay at home,” says Andrew. “We like to start outpatient physical therapy within one to two days of surgery. Getting to PT tends to be good exercise and a good kind of functional mobility task. Often, just getting to therapy is therapy itself.”
“Pain, swelling and bruising are common in those first days post operatively, so therapy starts off pretty light and focusing on just getting the range of motion back in that first 24 to 48 hours after the surgery. We have about a six-to-eight-week window to restore your range of motion. Keeping your pain under control, modifying your activity, and keeping the swelling low are important to getting your fullest function back.”
For the first month post-surgery, your daily activities will revolve around caring for your joint,” Andrew continues. “We're asking you to take your medication at mealtimes. We're asking you to ice five to eight times a day. We’re asking you to do your exercises. This is the time people ask, “Why did I do this?’”
In the second month post-surgery, you start with some really light cardiovascular activity. It’s good for your heart and your circulation and how you feel. A lot of very basic quad setting and quad strengthening exercises that are non-weight bearing and then eventually getting back to more aggressive, weight bearing exercises. Daily tasks are easier, you are able to climb steps pain free, you have improved walking endurance, more normal sleep patterns, and you may have returned to work. “Now you are starting to say, “I understand why I did this.’,” says Andrew.
By month three, most people have good pain control and have returned to all activities with improved function compared to pre-surgery. “I am typically discharging people out of PT between 8 and 12 weeks postoperatively. And I do ask that you please do your exercises three times a week until you're at least six months out. But at month three, this is when I hear “Why didn’t I do this sooner?” says Andrew.
Bonus Q & A with our Physicians
Q: What is the long term follow up protocol for knee replacement surgery?
Dr. Kelly: In general, I will see you at two weeks, at six weeks, and at three months after surgery, checking on the incision and making sure things are healing properly. I’ll see you again one year after the surgery. We’ll get an X-ray to compare against your previous X-rays. Then I like to see people back on a three-year basis.
Andrew: While you are typically discharged from physical therapy at 8 – 12 weeks post-surgery, continued strengthening exercise is highly recommended. We generally say your recovery tops out at 12 - 18 months.
Q: Are there body weight limits to various knee replacement options?
Dr. Palmer: We make recommendations for optimizing body weight for a variety of reasons. One significant reason is that it effects the longevity of the replacement. We generally want patients optimized at a healthy BMI, ideally below 35, if possible. but it’s a personal discussion with the surgeon. There is an exponential increase in complications as BMI increases. The rate of complications seem to go up significantly at a BMI of 40.
Q: I have osteoporosis. How will that impact either knee surgery or recovery?
Dr. Palmer: There are medications that can be used to help strengthen the bone as much as possible. We also cement the implants to help protect the bone.
Q: I need both knees replaced, but they are so bad I don't think I would be able to do one at a time; I would like to have bilateral surgery done. Is that something that you would recommend?
Dr. Palmer: That’s a personal decision between you and your surgeon, but there are more than two times the risks of complications with bilateral surgeries. It is not done routinely. Your surgeries can be staged at a short interval of potentially 6-12 weeks.
Q: Could you comment on patellar chondromalacia-diagnosis and non-surgical treatment options?
Andrew: Chondromalacia means "wear and tear" in the cartilage. For some, that just means we need to get your knee more flexible or improve your strength to protect the joint with activity. In addition to physical therapy, injections may help.
Q: How do we get pre-operative physical therapy treatment?
A: When you are scheduled to have a joint replacement at The Christ Hospital, you are referred into our physical therapy program and begin sessions prior to your scheduled surgery date. You can also be referred to physical therapy at The Christ Hospital by any doctor, an orthopedist, or your primary care physician.
Q: What would be some of the reasons for feeling some pain just below the kneecap while jogging?
Dr. Palmer: Typically, anterior knee pain just below the kneecap is caused by tendinitis of the patella tendon. This is also more commonly referred to as runners’ knee.
Q: Is stretching one of the best ways to overcome patella tendinitis/runners’ knee?
Dr. Palmer: Yes, quadriceps strengthening exercises and flexibility work. Also make sure you have excellent technique with running.
Q: what exercises should we NOT do to help save our knees?
Dr. Palmer: High impact exercise (lots of jumping).
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