A continuum of treatment for knee pain
Nearly all of us will have knee pain at some point in our lives and for some of us, it can be debilitating.
In my clinic, most people with knee pain fall into one of two categories. The first is people in their 20s and 30s who have an acute injury and a torn meniscus, which is the cartilage that cushions our knees. If physiotherapy fails to help them, these young people can be easily treated with a surgery called knee arthroscopy, which is a minimally invasive 20-minute operation.
The second group is older people with early to moderate arthritis, which is a breakdown of the cartilage that covers our joints. This creates an inflammatory condition that also results in tears to the menisci — this kind of chronic knee pain requires an entirely different approach.
Treatments aren’t always complex or invasive. For example, one of the best treatments for a bum knee is the one you’d least expect: exercise it.
The vast majority of people with moderate arthritis and knee pain can do very well just by taking simple measures such as doing some physical activity.
Although many of my patients tell me they already do things such as walk to work or use an elliptical trainer, the biggest benefit comes from focused exercises that strengthen your quadriceps and hamstrings. Think cycling, either on a traditional or stationary bike. Going to the gym once a week for half an hour to do weight exercises such as squats, hamstring curls or leg presses can also be effective.
Although losing weight is easier said than done, particularly if you already have knee pain, that can also help.
I’m an orthopedic surgeon, but I spend 90 per cent of my time working to keep my patients out of the operating room. I think of treating knee pain as an algorithm — starting with the simplest, least invasive interventions and moving along the continuum toward more aggressive treatments until we find the right one for you.
Knee replacement surgery is at the far end of the spectrum. Developed more than 40 years ago, this operation was once seen as miraculous. It helped a lot of people whose arthritis diminished their quality of life and left them unable to walk. Although about 80 per cent of people are satisfied with the results of their own surgeries, it’s a big procedure and it can take three to six months to recover. Major complications can also pose other risks to your health.
Although many people might like to take a magic pill, unfortunately, there isn’t one. Regular pills such as anti-inflammatories can be hard on our stomachs. Once you get older, it’s a good idea to be mindful of how many daily medications you’re taking and how they might interact with one another.
Many people ask me about cortisone injections. But this powerful anti-inflammatory medication typically only provides relief for a few weeks at a time. It is sometimes helpful for managing pain — for example, if your daughter’s wedding is coming up and you want to dance the night away or if you’re about to take once-in-a-lifetime hiking trip to Machu Picchu — but, sadly, cortisone isn’t a long-term solution.
There are a few other injections available, but they also have their limitations. Hyaluronic acid is readily available and covered by insurance. But it isn’t always effective and some people have allergic reactions to it.
A newer treatment called platelet rich plasma, or PRP, involves taking a blood sample, putting it into a machine to extract platelets and growth factors and then injecting the PRP into the knee. It’s effective for about 80 per cent of people, but unfortunately it isn’t covered by OHIP or insurance.
As a clinician scientist, I’m involved in trying to find new ways to help people manage their pain. A long-acting pain relief injection is the holy grail of treating knee arthritis. One of the things I’m studying is a bone marrow aspirate concentrate called BMAC to see if it might be more effective than cortisone.
This involves performing a biopsy to take a sample of bone marrow fluid and removing the stem cells. It’s an invasive process that hasn’t been around for very long, and is not completely understood.
In a perfect world, clinicians like me would be able harvest a patient’s stem cells and multiply them to make millions more. These stem cells could then be used to make a powerful anti-inflammatory. Right now, our laws don’t allow scientists to manipulate stem cells outside the body, but maybe one day we’ll be able to explore whether or not this could be a way to help people manage pain.
In the meantime, the best plan is to start simple. Take care of yourself and move more.
Dr. Tim Dwyer is an assistant professor in the Faculty of Medicine’s Department of Surgery, Division of Orthopaedic Surgery. He is also the educational director in the University of Toronto Orthopaedic Sports Medicine Program based at Women’s College Hospital. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email email@example.com .