Ladder of Treatment for Osteoarthritis of the Knee This leaflet will give you a short introduction to the treatments used for knee osteoarthritis. Knee osteoarthritis affects each person in different ways so not all these treatments may be right for you. The best treatment for you will depend on: Anti-inflammatory tablets. These tablets are usually recommended to help with pain if paracetamol has not worked for you. This group of tablets includes NSAIDs such as ibuprofen and diclofenac and COX-2 agents such as celecoxib. In a few people they may cause unwanted effects, particularly ulcers and bleeding in the stomach. If you are at risk of these side effects your doctor may recommend other tablets to prevent this(4). Glucosamine tablets. Taking these tablets regularly can help by reducing pain and allowing you to be more mobile. X-rays of the knee also show that in some people they stop osteoarthritis getting worse(5). Injections into the knee Your knee o o o How much pain you get How well your knee functions The amount of damage in the knee Your overall health Your doctor can help you decide which treatments are best for your knee. Things you can do Healthy eating to stay at a healthy weight. If you are overweight losing weight can make a big difference to your knee problems. Losing 5% of your weight can reduce pain and improve function(1). Make changes to help you cope. It is important that you learn the best ways to manage your knee day to day. Most people find that they get less pain after learning about osteoarthritis and ways to cope. You can find out more from the list of contacts at the end of this leaflet. Exercise. Regular exercise can help to keep you more mobile and make your knee less painful. Exercise also makes people feel their overall physical health is better. Many different types of exercise can help, the most commonly recommended include; walking, cycling, swimming and strength training for quadriceps (thigh) muscles(2,3). Physiotherapy can help you make the most of the function in your knee – it involves much more than just strengthening muscles. Flexibility, muscle control and overall fitness and stability can all be improved resulting in improvement in pain, easier movement and better function in the knee (6,7). Knee braces. If your leg is slightly bowed or knock knee’d then an ‘unloading’ type knee support can help reduce pain and improve stability. Injections of steroids. Steroids have a short lasting effect of about 1 month, reducing pain and swelling. It is usually used to treat flareups of arthritis pain(4). o Viscosupplementation Injections (e.g. Synvisc). This liquid boosts the normal ‘oil’ in the knee and may relieve pain and allow you to be more active, lasting 6 months or more(8). Surgery – Operations on your Knee Keyhole knee washout (Arthroscopy). This is a keyhole operation to wash out the knee joint. Your surgeon may also remove some of the damaged tissue in the knee. This can help to reduce the pain in your knee but may not improve the function(9). Bone re-alignment operation (Osteotomy). When the leg is bowed or knock knee’d more weight is being taken on one side than the other, wearing that side out. ‘Osteotomy’ corrects that by cutting through the bone and correcting alignment, taking some stress off the knee and ‘buying time’ (10). Knee replacement (Arthroplasty). Knee replacement – top of the ladder - is indicated when pain is severe limiting walking distance to less than a mile, interrupting sleep and substantially affecting quality of life. The benefit needs to be considered against the risks of the surgery(4). Physiotherapy and Knee braces o Other sources of information about arthritis: Treatments your doctor might prescribe Arthritis Research Campaign Arthritis Care Painkillers. Most people find that taking paracetamol helps reduce their pain and it is often the first painkiller recommended. Painkiller gels and creams – ibuprofen and capsaicin creams both help by reducing pain in the knee. Both are safe to use over long periods(4). Linda Porteous Medical Student for the Knee Team, UHCW NHS Trust Version 2 March 2008 NHS Direct www.arc.org.uk 0870 850 5000 www.arthritiscare.org.uk 0808 800 4050 www.nhsdirect.nhs.uk 0845 46 47 48 For references list see www.timspalding.com Ladder of Treatment for Osteoarthritis of the Knee (1) Christensen R, Marie-Bartels E, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann. Rheum. Dis. 2007 4 January 2007;66:433-439. (2) Van Baar ME, Assendelft WJ, Dekker J., Oostendorp RA, Bijlsma JW. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomised clinical trials. Arthritis and Rheumatism 1999;42(7):1361-1369. (3) Devos-Comby L, Cronan T, Roesch SC. Do Exercise and SelfManagement Interventions Benefit Patients with Osteoarthritis of the Knee? Journal of Rheumatology 2006;33(1):744-756. (4) Jordan KM, Arden NK, Doherty M. Recommendations 2003: an evidence based approach to the management of knee osteoarthritis. Ann. Rheum. Dis. 2003;6:1145-1155. (5) Richy F, Bruyere O, Ethgen O, Cucherat M. Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis. Archives of Internal Medicine 2003;163(13):1514-1522. (6) Ottawa Panel Members , Ottawa Methods Group , Brosseau L, Wells GA, Tugwell P, Egan M, et al. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis. PHYS THER 2005 September 1;85(9):907-971. (7) Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell J, McColl G, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2005;64:906-912. (8) Dagenais S. Intra-articular hyaluronic acid (viscosupplementation) for knee osteoarthritis. Issues in emerging health technologies 2006 December;94(94). (9) National Institute for Health and Clinical Excellence. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (interventional procedures second consultation). ;Consultation Document. (10) Dowd GSE, Somayaji, H.S. and Uthukuri, M. High tibial osteotomy for medial compartment osteoarthritis. Knee 2006 Mar 2006;13(2):87-92.