How to Manage Knee Osteoarthritis

The goal of nonoperative treatment of OA is to provide pain relief and improve function, while limiting potential adverse side effects of treatment. Nonoperative treatment encompasses all efforts short of knee replacement surgery. The American Academy of Orthopaedic Surgeons (AAOS) has published evidence-based guidelines of management options for surgeons to reference. It is important to make sure treatment options have sound scientific evidence of efficacy to avoid wasting patients’ time and resources and avoid unnecessary risks of treatment.

Dietary supplements are an alternative to pain medications. These include glucosamine, chondroitin, turmeric, ginger extract and vitamin D. Evidence demonstrates either some improvement or no change in patient outcomes with these supplements, and does not consistently demonstrate any benefit. There is limited oversight by the U.S. Food and Drug Administration, causing variability between manufacturers. Despite the lack of reproducible evidence, supplements carry low risk of adverse side effects. The primary downside is out-of-pocket expense to the patient.

Over-the-counter pain medications including oral nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol) have a strong recommendation from the AAOS, with studies showing consistent improvements in pain and function. Celebrex is an NSAID that was developed to reduce the risk of gastrointestinal problems, although there is limited evidence that it significantly decreases this risk.

Oral narcotics (Tramadol, Norco, Vicodin, Oxycodone) are NOT recommended for the treatment of arthritis, with strong evidence of increased adverse effects. They do not consistently improve pain and function.

Injections are used frequently, with the most common being corticosteroid, hyaluronic acid (HA, or gel), and platelet-rich plasma (PRP). Corticosteroid injections have many high-quality studies showing significant improvement for about 3 months. It is covered by insurance and is low-cost for patients. The AAOS does NOT recommend HA injections because evidence from numerous studies shows a low likelihood of clinical improvement. Approximately 1 in 17 patients will experience improvement with HA injection. There is limited evidence that PRP may reduce pain and improve function for up to 12 months. Some evidence shows three injections may be better than one or two, and leukocyte-rich PRP may be better than leukocyte poor PRP. However, PRP tends to be expensive and most insurance providers do not cover it.

Other treatment modalities with strong evidence of efficacy include exercise (supervised, unsupervised or aquatic), and patient education programs that aim to teach patients medication compliance, pain coping strategies, and joint protection strategies during activity and exercise. There is moderate evidence that weight loss, knee braces or cane use can be helpful. Modalities such as massage therapy, laser treatment, acupuncture, transcutaneous or percutaneous electrical nerve stimulation, extracorporeal shockwave therapy, and denervation therapy have only limited evidence of reducing pain and improving function.

Knee OA can be managed with these treatments as long as they are effective. Once pain and function are no longer improved with non-operative options, it is reasonable to consider surgery. Typically, knee replacement is the best surgical option for knee OA. The necessity and timing of surgery is different for every patient, and is best decided through a personalized discussion with a joint replacement specialist. FBN

Liam Bosch, M.D.

Dr. Liam Bosch is a fellowship-trained orthopaedic surgeon who brings his expertise in hip and knee replacement to Flagstaff Bone and Joint and cares for patients suffering from arthritis. Additionally, he specializes in conducting revision surgeries for knee and hip implants, addressing any complications that may arise. With a dedication to utilizing cutting-edge techniques, Dr. Bosch offers advanced procedures, such as anterior total hip arthroplasty and robotic total knee arthroplasty. His commitment to providing exceptional care and innovative treatments makes him a valuable asset to Northern and Central Arizona. For further information, please visit: www.flagstaffboneandjoint.com.