Try PT and injections to fight knee pain

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Knee pain caused by worn cartilage due to arthritis or a torn meniscus can be so debilitating that you find yourself unable to exercise, go the grocery store, or even walk across a room. While surgery is often the fix, it’s not always necessary to relieve knee pain.

“I see surgery as the last resort,” said Dr. John Melmed, who focuses much of his practice at the Silver Spring Medical Center in Maryland on knee pain.

Melmed is a firm believer in having someone try physical therapy, weight loss (which helps take pressure off the knees), and other less invasive treatments before resorting to knee surgery. There’s science to back up that concept.

Physical therapy is effective

A study published in Arthritis and Rheumatology found that about a third of total knee replacements in the United States are inappropriate, suggesting that many people undergo knee replacements unnecessarily. There are about 700,000 total knee replacements performed each year in the United States.

A New England Journal of Medicine study showed that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee. The study, led by Dr. Clare Safran-Norton, clinical supervisor of rehabilitation services at Harvard-affiliated Brigham and Women’s Hospital in Boston, found no significant differences in functional improvement after six months between patients who underwent surgery with postoperative physical therapy and those who received physical therapy alone.

Safran-Norton, a physical therapist, recommends that a person with knee arthritis or a torn meniscus undergo at least three months of physical therapy as a first line of treatment.

“There’s a lot we can do with stretching and therapeutic exercise,” she said.

Why exercise helps

The first step is to begin a series of exercises to strengthen muscles that work with the knee, including the quadriceps and hamstrings in the thigh, the gluteal muscles in the buttocks, and the abdominal muscles. If these muscles are stronger, they’ll absorb more of the pressure you place on your knee, which will relieve pain.

The second step is to stretch the muscles that support the knee, such as the thigh and calf muscles, as well as the iliotibial band — a thick cord of connective tissue that runs along the outside of your leg — to keep them all healthy, flexible and resistant to injury. This type of strengthening and stretching program provides relief within weeks.

The following exercise works your abdominal muscles and inner thigh muscles, and can be done on a mat, a bed, or even a couch: Lie on your back with your knees bent and feet flat. Put a small ball (roughly 12 inches) between your knees. Place your arms at your sides. Tighten your abdominal muscles. Squeeze your knees together against the ball. Hold, then release. Repeat eight times.

Lubricating injections

Even with exercise and therapy, many patients find that knee pain can persist. The next step for some doctors is a corticosteroid injection into the knee joint, which can temporarily reduce pain and swelling. The injections can help for up to six months, depending on how advanced the arthritis is, said Melmed.

Another option for those with osteoarthritis is to inject a lubricating fluid into the knee joint. In this procedure, called  viscosupplementation, a naturally occurring substance in joints called hyaluronic acid, is injected. The thick, oily substance helps facilitate movement of the joint and reduce pain.

Dr. Brian Paris of Advanced Wellness Systems in Rockville, Md., explains the need for lubrication around the joints like this:

“As the knee joint weakens, the fluid starts to dissipate out of the joint, and then it becomes arthritic. It just becomes very rusty,” he said. “The best analogy I can use is like the Tin Man [in The Wizard of Oz]. When Dorothy gives him the oil, he can actually move his joint.”

The hyaluronic acid is derived from an unusual source — the comb of a chicken, which is filled with hyaluronic acid.

Both Paris and Melmed guide the needle into the right place with use of imaging. To precisely inject the fluid, Paris uses fluoroscopy, which uses X-rays to pinpoint the joint, while Melmed guides his injections with ultrasound, which uses sound waves to form an image of the joint.

Patients get up to five weekly injections, and pain relief can last up to two years. Both doctors advocate additional physical therapy after the treatment to ensure the joint remains limber.

The course of treatment is covered by insurance and Medicare every six months.

 Safran-Norton noted that studies about whether acupuncture relieves knee pain are mixed, but she said that the treatment is helpful to some people.

Research is also mixed on whether chondroitin and glucosamine supplements relieve pain, but Safran-Norton noted that some people feel the pills make a difference.

— Harvard Health Letter, with additional local reporting by Barbara Ruben

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