What is the best treatment for arthritis in a runner’s knee?

Total knee replacement remains the “gold standard” for the treatment of osteoarthritis.

The principle function of cartilage in a joint is to serve as a resilient but elastic structure that reduces the stress between bones and allows smooth articulating movement so you can run, jump, and bend. There is little or no capacity for cartilage to heal once injury has occurred because this tissue is designed for longevity through maintenance, not repair. With neither blood supply nor nerves to facilitate the healing process, damaged cartilage is challenging but not impossible to repair.

So do not fear: there are several conservative and surgical treatment options for knee osteoarthritis (OA). Depending on how early the diagnosis is made, there are some factors that will help to determine what the best treatment will likely be, such as your age, how significant the cartilage damage is (the morphology-based Mankin Scale is commonly used), how many surfaces in your knee joint are affected, the time frame for how quickly you need or want to get back to work or activity, as well as whether you plan to return to competitive sports. The first step is to get a professional assessment of your knee by a sports medicine physician or an orthopaedic surgeon that includes appropriate diagnostic imaging. If you are diagnosed with OA and the size and severity of the cartilage damage is known, then you can begin to explore how best to proceed.

Pain Relief

One of the first lines of ‘defence’ to help reduce the pain and inflammation is to consult with your physician or pharmacist regarding an anti-inflammatory medication. Acetominophen (Tylenol) can be effective for milder pain. If you have more severe OA and hence greater pain, then NSAIDs (non-steroidal anti-inflammatories) may provide better pain control. There are non-selective NSAIDs (Motrin, Advil) and selective COX-2 inhibitors (Celebrex); however, you need to consult with your physician as to which type is the most appropriate for you.

Glucosamine

What about glucosamine and chondroitin? Both are components of cartilage that are thought to help slow the progression of OA. A recent multicentred study from the National Institutes of Health in the United States concluded that glucosamine may help patients with moderate to severe OA of the knees. Of interest, the authors stated that for mild OA cases, glucosamine had no effect. This landmark study has been obtaining data since 1999, and it seems that there is generally a lack of positive response compared to placebo in people taking glucosamine. The jury is still out.

Quads and Weight

Physical therapy treatment has been shown to be very effective in relieving pain and increasing function. The literature and clinical practice support two conclusions: one is increasing quadriceps strength, and the other is to reduce weight if the patient is obese. Quadriceps strengthening is paramount and helps to reduce the compressive forces through the knee joint. Weight loss also reduces the compressive force at the joint level. This makes sense intuitively. Research reveals the benefit of the combination of manual techniques in treatment, coupled with high- or low-intensity aerobic exercise to reduce pain, increase function, and improve gait.

Orthotics

From a biomechanical perspective, orthotics and braces can be used to help decompress the joint surfaces. Various knee braces are on the market that can “unload” the joint while one is walking. Foot orthotics are used to help change the foot mechanics, which, in turn, can change the knee mechanics. Various studies in the literature either refute or support this change in mechanics rationale. So, once again, the jury is still out.

Fluid Injections

Joint fluid therapy is a non-surgical treatment option for patients who have failed to get adequate relief of their osteoarthritis symptoms from over-the-counter painkillers or from exercise and conservative treatment. The viscosupplementation is composed of highly purified sodium hyaluronate (hyaluronan). Hyaluronan is a natural polysaccharide found in the connective tissue throughout your body, particularly in joint tissues and the fluid (synovial fluid) that lubricates and protects the joints. The hyaluronan is administered by your physician through a series of three injections directly into the knee joint with doses ranging from eight to fifteen milligrams per millilitre (depending on the product). Some patients experience relief for several months, whereas others report no benefits. It is unclear why viscosupplementation seems to work for only some patients.

Knee Replacement Surgery

For other patients, surgery is the best option. Of all possible treatment options for varying degrees of osteoarthritis, total (artificial) knee replacement (TKR) is the most extreme. As a result, most surgeons will not consider performing a TKR unless you are fifty-five years or older with significant osteoarthritis that affects more than one joint surface. This procedure involves replacing the three surfaces in your knee with metal and plastic implants that mimic natural joint movement; however, they often last only ten to fifteen years. The potential for revision is limited (i.e., it becomes more challenging to do a second TKR on the same knee), and therefore the goal of all other treatments is to delay the need for a TKR until it is absolutely necessary. TKR is a well-established procedure that results in significant improvement in pain, function, and overall quality of life for the majority of patients. Implant designs continue to evolve, and over the past few years the use of gender-specific implants has increased dramatically.

Fibrocartilage

Until very recently there have been no effective treatment options for patients under the age of fifty-five with cartilage injuries. Debridement and microfracture are arthroscopic (minimally invasive) surgical procedures often used as a short-term solution to stimulate bleeding and the formation of fibrocartilage in an isolated area of cartilage damage. Fibrocartilage, however, has different properties than articular cartilage, so it does not function in the same way and will wear down over time.

Osteotomy

When you have arthritic damage on only one side of your knee, an osteotomy is often used to realign your joint and to shift your body weight off the injured area to the side of your knee that still has healthy cartilage. To accomplish this, the surgeon removes a wedge of bone from one side of your shin bone (tibia) to intentionally alter your joint alignment. An osteotomy can allow younger, active patients to continue using the healthy portion of their knee for approximately another ten years.

Partial Knee Replacement

A unicompartmental knee replacement is another treatment option that is sometimes used when only one side of the knee has been damaged by OA. The prosthesis replaces only a portion of your joint, leaving your knee cap, ligaments, tendons, and nerves intact.

Cell and Tissue Splicing

Autograft techniques such as mosaicplasty (taking bone and cartilage plugs from a healthy part of a joint to repair a damaged area) or autologous chondrocyte implantation (isolating cells from healthy cartilage and later re-implanting them into the damaged region) are also performed in a few centres across North America. Unfortunately, there are no studies with long-term results to provide evidence that these two techniques offer any more benefit to the patient than microfracture. In addition, creating damage in a healthy area of the joint to repair injury at another site in the same joint is inherently destructive.

Bone and Cartilage Transplantation

One of the most promising treatment options involves using donor articular cartilage to replace isolated regions of damaged articular cartilage that is size- and location-matched (osteochondral allografts) for patients who are not suitable candidates for total joint replacements. There is a need to use osteochondral allograft tissue because articular cartilage is a complex structure that cannot be made in any other way. Osteochondral allografts have been performed for over twenty-five years; however, the technique of transplanting bone with cartilage using specialized instrumentation and the ability to store this tissue for a period of time prior to transplantation are relatively new to orthopaedics. This treatment option is not performed more frequently or in many jurisdictions because the amount of suitable donor tissue available is often limited and there are few hospitals that have the resources to make this procedure a realistic option (a local tissue bank to supply safe donor tissues, storage techniques to preserve tissues effectively, well-trained surgeons who have experience performing these procedures, funds to purchase the surgical instrumentation, etc.).

There is little or no capacity
for cartilage to heal once
injury has occurred.

There is now a team of experts in Calgary and research that shows the effectiveness of these procedures. We also have the facilities to offer this treatment in Alberta as an option for patients.

According to Dr. Scott Timmermann, an orthopaedic surgeon, “A biologic solution to a disease with such incidence and devastating impact as osteoarthritis is the goal of many research labs today. Osteochondral allografting allows the opportunity to transplant healthy, live, size-matched and joint-specific cartilage tissue. To date we do not have any other options that slow, stop, or reverse the degenerative process and its overwhelming personal and socioeconomic impact.”

Cell Growth and Replacement

The future of bone and joint research is moving towards using cells and tissues that naturally exist within our bodies to repair damage. Tissue engineering and the use of embryonic stem cells are two areas of great interest in regenerative medicine. As Dr. Derrick Rancourt, director of the Embryonic Stem Cell/Targeted Mutagenesis (ESTM) Facility at the University of Calgary, explains, “The future of OA research will be centered upon early diagnosis and treatment. As stem cells have shown promise for repairing skeletal injuries in animal models, there is promise that early therapeutic intervention may be as simple as administering an injection of stem cells into the knee joint and monitoring repair using non-invasive imaging.”

Currently, a total knee replacement remains the “gold standard” for the treatment of osteoarthritis; however, degenerative joint disease does not occur overnight. As a result, a number of interventions, sometimes used in combination, are often the best treatment for delaying the progression of OA. There is no cure for OA at present, so early identification and proper management of joint injuries that could potentially lead to OA are essential.

About the Authors

Sue Hunter is the coordinator of the Joint Transplantation Program at the McCaig Institute for Bone and Joint Health in Calgary, Alberta, and has a Master’s Degree in Medical Science, specializing in Joint Injury and Arthritis Research.

Dr. Michael Westaway is a consultant orthopaedic physical therapist. He practices at the Westside (SW) and Village Square (NE) Clinics in Calgary, Alberta. He is a spinal consultant to the Calgary Flames Hockey Club and a certified ART provider. Dr. Westaway can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .