Surgery isn’t only answer for knees

Times Staff Writer

The prognosis for people with knee osteoarthritis isn’t so bleak as it might seem in the wake of a study finding that arthroscopic surgery, once hailed as promising, may not be the best option.

That study, released in the Sept. 11 issue of the New England Journal of Medicine, suggested that those who underwent the surgery didn’t fare any better in the long run than their counterparts who received physical therapy. During the surgery, small incisions are made through which a small camera and surgical instruments are inserted. Physicians can then repair or remove cartilage, or flush the knee to remove debris -- or do both procedures.

The trick is to find one or more treatments -- amid the array that includes medication and physical therapy -- that can ease the pain of worn cartilage. It can take some work.


“When patients come into my office,” says Dr. Ronald Grelsamer, a knee surgeon in the orthopaedics department at Mount Sinai School of Medicine in New York, “I give them a list of 17 options to help them manage their condition. At the very bottom is arthroscopy. It works for a little while, but it’s not going to cure it. . . . What I’ve found is that nothing works for everybody, and everything works for somebody.”

Oral nonsteroidal anti-inflammatories, such as Celebrex, can reduce inflammation and pain, as can cortisone injections. Hyaluronic acid injections can replace some of the viscous synovial fluids that lubricate the joints but that sometimes decrease with age. Acupuncture and massage may also alleviate pain. But as people get older and knees become more worn, the ultimate remedy could be a total knee replacement.

And although a New England Journal of Medicine study in 2006 found that glucosamine and chondroitin supplements fared no better than a placebo among 1,583 people in reducing knee pain by 20%, some doctors still recommend it. “The average effect is quite small,” says Dr. John FitzGerald, assistant professor of rheumatology at the David Geffen School of Medicine at UCLA, “and it can be slow-acting. That study is open to interpretation; I think on average it works a little bit for some people.”

But much can be said for consistent exercise, which can also tamp down pain and improve mobility, according to health experts. One study published in the Annals of Internal Medicine compared a physical therapy program of manual therapy and exercise with a placebo program of subtherapeutic ultrasound, and it found that exercise improved walking distance and function, pain and stiffness scores far greater than the placebo.


Shed some pounds

A good first line of defense, health experts say, is shedding some pounds. “You can get some long-lasting effects,” FitzGerald says. Even a little makes a huge difference, because walking and running can put extra force -- equivalent to several times one’s body weight -- on the knees with every step. “Even with 5 to 10 pounds, which is a reasonable goal, people can expect a fairly significant improvement in knee pain,” he says.

The recommendation comes with a snag, however: When knees hurt, the motivation to exercise goes south.


“Unfortunately, you can’t wait for the knee to get better to start exercising,” FitzGerald says. “Start exercising, and then the knee will get better.”

Laura Bennett, a physical therapist who works with osteoarthritis patients at L.A.’s Good Samaritan Hospital, has a use-it-or-lose-it philosophy when it comes to battling osteoarthritis.

“If we don’t use it, we lose strength in our muscles and range of motion,” she says. “We can compensate for a while, but if we become stagnant in our movements, then our joints don’t get the fluid they need, which means they don’t get the nutrition they need, then arthritis sets in, and it hurts to move, so we don’t want to move.”

Walking, swimming and water workouts are great for some with arthritic knees, Bennett says. “Being in the water takes a certain amount of body weight off the knees and hips. Joints have an easier time moving and the water gives muscles some resistance.” Walking time and intensity should progress gradually, she says. Many physical therapists will examine patients’ muscle strength and flexibility from their feet to their hips and back, plus assess alignment and gait, possibly prescribing exercises and stretches to correct disparities and weaknesses.

“A lot of times with osteoarthritis,” Bennett says, “it could be a muscle imbalance that’s causing it, where one side might be weaker and one side is tighter, and people are not working at a biomechanical advantage.” It’s also not just the knees that are worthy of attention -- other joints that support them, such as the hips and ankles, are important to shore up as well.

Depending on the person, therapy might include a hamstring stretch that can be done sitting or lying down (stretching muscles helps increase joint flexibility). In that move, a belt is looped around one foot and the straightened leg lifted until a stretch is felt along the back of the leg. This can be repeated three times and held for 30 seconds on each leg. External hip rotators, which are part of the kinetic chain that supports the knee, can be strengthened by lying on one side with knees bent, the top leg raised like a clamshell. (Note: No exercises should be attempted before consulting with a physician or licensed physical therapist.)



Take a load off

In examining movement patterns during walking or running, Christopher Powers, associate professor of biokinesiology and physical therapy at USC, looks for “dynamic misalignment,” checking to see if knees fall inward or if there’s an abnormal rotation at the hip or foot. These, he says, can put undue torque and stress on the ligaments, joints and cartilage. Therapy, he adds, can take some of those stresses off the knee joint.

Because biomechanics vary from one person to the next, therapy programs need to be tailored but may include working with patients to change their gait -- not always an easy task, considering that walking is something most people do automatically. “The patient has to be aware of what they’re doing and why they’re doing it,” he says.

“Your muscles are kind of like shock absorbers,” Powers adds, “and when they’re not working well, you start to rely on your passive shock absorbers, like your cartilage and bone.”


Patients may be able to get referrals for licensed physical therapists from their doctors or hospitals. The American Physical Therapy Assn. also has lists of members on its website,