Osteoarthritis is the most common form of chronic arthritis, with more than 50% of people over the age of 65 having either signs or symptoms of the condition.

Osteoarthritis is characterised by pain in the joint, impaired mobility, and mechanical symptoms such as locking, swelling, or the feeling of the joint giving way. It occurs due to a gradual wearing of the cartilage that overlies the bones. There are many causes of osteoarthritis, however the most common cause is idiopathic so-called wear and tear and is age-related. There is currently no cure for osteoarthritis. Treatment is aimed at symptomatic relief and improving the function of the joint. This aims to optimise the quality of life for the patient.

The treatment for knee osteoarthritis can be considered broadly into 2 categories, those being either  nonsurgical or surgical. Surgery typically involves a joint replacement and is a cost-effective intervention for people who have severe osteoarthritis that has not responded to conservative management and it’s impacting on the patient's quality of life.

There are a number of non-surgical options that have been recommended by the National Health and Medical Research Council. These recommendations are useful in providing symptomatic relief and serve as the basis for nonsurgical intervention. These interventions may avoid or delay the need for joint replacement surgery. The treatment needs to be tailored to the individual patient and should be discussed both with your specialist and general practitioner.

Weight control

There is good evidence that weight reduction for patients who are overweight leads to an improvement in the symptoms of both pain and disability. It has been estimated that if all overweight people reduced their weight by 5 kg or were within a normal body mass index, approximately 20 to 50% of all joint replacement surgery could be avoided. Multiple options exist for weight reduction including surgical, pharmacological, and nonpharmacological treatment options. Consultation with a dietician and your general practitioner is recommended.

Exercise

Increasing physical activity has many benefits for one's health.  It has been shown to reduce the risk of multiple chronic diseases, assists weight control, improves mental health, may include social benefits, and overall is believed to improve people’s quality of life. A range of supervised and home-based exercise programs are available that target quadriceps strength, overall muscle strength, and flexibility exercises. An exercise program requires individuals to actively participate in a program. This may include the assistance of a qualified professional such as a physiotherapist or exercise physiologist. Alternatively, some patients may already attend group classes such as Pilates or tai chi. Water-based exercise programmes may also be beneficial. In some cases, simply regularly walking on a flat or gently undulating surface may be all that is required and patients should be encouraged to maintain being active, as a significant number of people will find movement to be actually pain relieving.

Physiotherapy

An assessment by a musculoskeletal physiotherapist aimed at relieving pain, improving stiffness mobility and overall muscle and joint function is recommended. Therapy generally consists of range of motion exercises, soft tissue mobilisation, muscle strengthening, stretching and other useful coping strategies.

Self-managed education programs

There is some evidence to support recommending self-management programs. These aim to help people with arthritis improve their management of pain and quality of life. They include expertise from a variety of healthcare professionals. New South Wales Health provides an osteoarthritis chronic care program that is available to patients that have been referred by a specialist. Medium to long-term self-management support may also be provided by Arthritis New South Wales.

Hot and cold therapy

There is some evidence that cold therapy may help treat the symptoms of osteoarthritis. Cold therapy reduces swelling and inflammation, improving muscle spasms and pain. Treatment is usually most effective when minor inflammation is present and is administered through the application of an ice pack wrapped around a towel for 20 minutes twice per day, 5 days a week, for 2 weeks. Heat may reduce pain and stiffness through the promotion of muscle relaxation, joint flexibility in blood flow to joint. Some commercial devices are now available that provide both compression and cold therapy to the limb. These devices are available for hire. Please enquire with the administrative staff for details regarding hiring.

Pharmacological treatment

Paracetamol

There is good evidence to support the use of paracetamol with regular divided doses up to a maximum dose of 4 g/day. Paracetamol is an oral analgesic of choice for the management of osteoarthritis. It reduces pain and fever and should be used in mild to moderate osteoarthritis. People with underlying liver disease or with a low body weight may need to lower the dose. Advice should be sought from your general practitioner regarding the appropriate dose.

Oral nonsteroidal anti-inflammatories

There is good evidence to support the use of anti-inflammatories, however this should be done in conjunction with your general practitioner. Anti-inflammatories reduce pain and inflammation and have been shown to be effective for mild to moderate osteoarthritis. They do have a number of side effects such as causing reflux,  possible increased blood pressure, potential allergy, and they cannot be used during pregnancy. They should be used in conjunction with paracetamol.

Topical anti-inflammatories

Some topical anti-inflammatories  can provide short-term treatment for osteoarthritis. They may reduce the amount of inflammation and are particularly useful for joints that are close to the skin, such as the knee joint. However, topical absorption of drugs is usually poor.

Other supplements

Glucosamine and chondroitin

These medications were initially thought to promote the prevention of osteoarthritis by preventing cartilage breakdown. However, the evidence supporting this has not been found and they have been shown to be of little benefit. Whilst there is no evidence to support their use, they are relatively safe, and some patients do experience benefits from taking them. 

Fish oil can also be taken. It is proposed to reduce general inflammation in the body and therefore reduce pain related to inflammation from osteoarthritis. However, there is little evidence to support the use. 

Turmeric is a new supplement that has drawn increasing attention in the last few years. There is some early evidence to support its use in the treatment of the symptoms of osteoarthritis. There is no evidence to suggest  turmeric can prevent or cure the disease. Patients should consult their general practitioner before taking these medications as they may induce other enzymes in the liver, particularly for those patients who are already taking other medications.

Knee braces and sleeves

Some knee braces have been designed to take pressure off a certain part of the joint that may be affected by osteoarthritis. There is limited evidence that knee braces for knee osteoarthritis work. Some patients experience no benefit whatsoever, whilst others report modest improvement. Unfortunately, the bracing is bulky and cumbersome, and most patients do not feel that they are a viable long-term solution.

Taping has been a useful adjunct that has been employed by physiotherapists to treat pain from the patellofemoral joint. Taping performed by physiotherapists can be taught to patients. Whilst taping can cause skin irritation, it is relatively safe and has been shown to be quite useful for people with pain related to the patellofemoral joint. Wearing shock absorbing footwear with a good arch support and calcaneal cushion can improve pain in some patients. Certain inserts such as a lateral heel wedge may reduce pain in the medial or inner part of the knee joint. Walking aids may be beneficial to some patients, especially during an acute exacerbation of the knee osteoarthritis

Injectables

There are a number of injectables available for the treatment of knee osteoarthritis. The most common is a corticosteroid which is an anti-inflammatory. An injection of this into the joint reduces the systemic side effects from this medication. It is very useful in treating acute short term severe pain. Unfortunately, its effect is usually short lived, usually wearing off around 6 to 12 weeks. It also increases the risk of a prosthetic joint infection if the surgery is performed in 6 months of an injection. The main risk of a corticosteroid injection is an infection, which is generally quoted to be around 1 in 800 cases/patients.

Viscosupplementation

Viscosupplementation is a synthetic lubricant aimed to have a cushioning effect on the joint. There are a number of products available. Some are a pure synthetic lubricant whilst others admix an anti-inflammatory with the viscosupplementation. The latter are generally more effective at relieving pain. These injections generally provide a longer-term benefit lasting anywhere from 6 to 12 months but are far more extensive than a corticosteroid injection.

Platelet rich plasma

Platelet rich plasma is the patient's own blood that is drawn with the use of a needle. Approximately 30mls is spun in a centrifuge which separates the various components of the blood. The top layer contains a concentrated amount of platelet cells. Within platelets, there are Alpha granules which have been shown to promote healing. The rationale for platelet rich plasma is that, by injecting a high concentration of platelet cells, the Alpha granules will be released and will nourish the cartilage making it more resilient and will also promote a more normal joint. Whilst the rationale is clear, the evidence has suggested a modest improvement in symptoms. The treatment can be expensive, with the current recommendation being 3 injections. There is also no evidence that it actually slows or prevents the progression of the disease. Its improvement in symptoms is more likely to be due to the fact that it has been shown in some studies to have an anti-inflammatory effect.

Bone marrow aspirate

This treatment involves taking a large bore needle and inserting it into the patient's bone, usually the pelvis. A quantity of marrow is aspirated and then spun in a machine. This contains primitive cells  called stem cells which are then injected into the joint. The rationale being that the cells can then differentiate into cartilage cells to prevent or treat osteoarthritis. Unfortunately, the evidence for the use is weak and the procedure is fairly invasive, usually requiring a light or general anaesthetic. It has been shown to be useful in the treatment of some fractures but its use in osteoarthritis at this stage is not supported by the evidence.

Adipose derived stem cells

A number of products have been made commercially available that harvest fat cells from the patient. These are then spun in a machine and admixed with some other substances and injected into the knee joint. Fat cells contain a cell called mesenchyme all stem cells. This is the lineage of cells that cartilage cells grow from. Whilst the rationale is enticing, the scientific evidence supporting its use has been weak and it has not been shown to be effective in the prevention of knee osteoarthritis. Dr Shatrov can discuss with you further should you wish to explore this option in more detail.

Nerve ablation or blood vessel embolisation

Osteoarthritis causes chronic inflammation around the joint. This inflammation can cause abnormal blood vessels or nerves to form, and these can cause increased pain. A treatment option that has been promoted recently is the ablation or burning of either the nerve or the blocking of some of these very small vessels. This is either done by radiofrequency ablation or an angiogram where the vessels are selectively coagulated or blocked. There have been some encouraging results for people with chronic pain. However, many concerns still exist about this therapy, including the concern that any future surgery on the limb may be affected if the blood supply has been blocked to that joint. Furthermore, the ablation of nerves to joint raises the concern of what’s called a ‘neuropathic joint’ developing, whereby a destructive arthropathy can ensue. Currently, these modalities are reserved for patients who are so medically unwell that they cannot receive another treatment option, or alternatively it is reserved for patients who have trialled all other methods and still have chronic pain.