Arthrosis of the knee and shoulder joints, symptoms and treatment

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Orthopedic traumatologist > Tips and recommendations > Conservative methods of treating deforming arthrosis of the knee joint.

Arthrosis deformans or osteoarthritis (OA) is a progressive disease leading to dystrophy and degeneration of articular surfaces and damage to cartilage, up to its complete destruction in the joint area. It is characterized by chronic, painful and debilitating inflammation in the joint area. About 242 million people worldwide have OA of the hip or knee, and about a third of chronic moderate to severe pain is associated with OA. The prevalence of OA continues to increase, which is associated with an increase in the number of older people and people with excess body weight. The pathogenesis of OA involves a complex interaction of mechanisms including genetic, mechanical, metabolic and inflammatory factors.

Pharmacological and non-pharmacological methods are used in the treatment of OA. When the latter become ineffective, surgical treatment options such as joint replacement are considered. However, joint replacement is not a cure for arthrosis. Up to 20-30% of hip and knee replacement patients report little or no improvement in arthrosis symptoms and/or dissatisfaction with their results one year after joint replacement.

Most people with OA have at least one other chronic condition, and the most common are various cardiovascular conditions. On average, people with OA have 2.6 moderate-to-severe comorbidities and 31% have five or more other chronic conditions. In particular, abdominal obesity and metabolic syndrome (obesity, diabetes, hypertension and dyslipidemia) are 2 times more common in people with OA than in control groups.

Considering the high prevalence of comorbid conditions among people with arthrosis of the hip and knee joint, it is simply impossible to perform joint replacement for everyone due to the high risks of surgical intervention. Many patients independently refuse the proposed operation, knowing about the possible development of postoperative complications.

There is a wide range of non-surgical methods to treat this category of patients. Although there is a large body of literature examining their safety and effectiveness, many treatments still lack consensus on effectiveness. The most available treatments for the successful management of knee OA are nonsteroidal anti-inflammatory drugs (NSAIDs), weight loss, intra-articular injections, physical therapy, and knee braces.

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Nonsteroidal anti-inflammatory drugs

In the last two decades, numerous studies have described the use of NSAIDs for deforming arthrosis of the knee joint . Many of these studies have shown that NSAIDs are relatively safe and effective in reducing pain and improving function over long-term use.

After taking the drug, the effect develops on average within 20 minutes. The mechanism of action of NSAIDs is inhibition of cyclooxygenase (COX). These are enzymes that are responsible for the formation of prostaglandins, prostacyclins and thromboxane. Prostaglandins are a group of physiologically active substances that are mediators of inflammation, and the more there are, the more pronounced the inflammatory process. NSAIDs, acting on COX, reduce the amount of prostaglandins, which causes a decrease in inflammation, thereby relieving pain.

Currently, the existence of 2 isoforms of COX is recognized - COX-1 and COX-2. COX-1 plays a critical role in protecting the digestive tract by producing prostaglandins to maintain the integrity of the gastric and intestinal mucosa. COX-1 also prevents spasm of the respiratory tract, regulates normal platelet activity, reduces tension in the vascular wall and affects kidney function.

COX-2 is not normally found in tissues, but appears only during the development of an inflammatory process. It is this enzyme that causes the main clinical manifestations of inflammation, namely pain, swelling, redness and fever.

New generation NSAIDs selectively act only on COX-2, which makes it possible to achieve the desired effects - analgesic, anti-inflammatory and antipyretic. Thus, the side effects of the drugs are significantly reduced, and the effect on the gastric mucosa, blood clotting and platelet function is minimized.

In studies, when compared with placebo, NSAIDs show improvements in pain levels and joint function without any serious complications over 6 months of taking the drug. However, we must remember that not all NSAIDs can be used long-term due to the possible development of side effects from the gastrointestinal tract, urinary and cardiovascular systems. It is also important to use the correct dosage of the drug, especially in elderly patients. Self-administration of NSAIDs by the patient may not give the desired result if the doctor subsequently prescribes a long course of treatment. NSAIDs are most effective when used chronically, but many patients will only use them when they have pain, leading to potentially suboptimal outcomes. It should be remembered that NSAIDs cannot cure OA. These drugs have only an anti-inflammatory and analgesic effect.

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How not to damage your joints while doing physical therapy

Date of publication: 05/17/2018

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Necessary caution when treating osteoarthritis

JSC Family Doctor - Manifestations of osteoarthritis

When you hit your knee and have to wince in pain, it is not surprising. Everything looks natural: there is a reason that caused the pain. But one day, knee pain may appear suddenly - for no apparent reason. The joints just start to hurt. When visiting a doctor, a person in this case usually hears a diagnosis of “osteoarthritis.”

Osteoarthritis (or simply arthrosis) is, so to speak, the destruction of a joint as a result of the natural process of its use. We inevitably put stress on our joints, and the tissues wear out. Tissue regeneration in the joints occurs, but it cannot fully compensate for strain caused by stress and degeneration associated with general aging of the body. Medicine defines arthrosis as a primary chronic disease. Once it begins, arthrosis tends to progress, and it is impossible in principle to return the joints to their original ideal state. You can only somehow improve the situation and slow down further destruction of the joint structures.

Previously, arthrosis was considered a disease of the elderly, but in recent decades it has become significantly younger. Now the disease often comes at forty and even thirty years of age. Among the reasons for this is an unhealthy lifestyle (low physical activity), as well as an “epidemic” of obesity (extra pounds overload the joints). It’s not for nothing that ancient doctors said that movement is life. Movement prevents muscles from atrophying and increases muscle tone. The joint space widens and spasms are relieved. The joint begins to work better (bend and unbend). Local blood circulation improves. As a result, pain decreases and joint destruction slows down.

That is why the complex of therapeutic measures for arthrosis necessarily includes physical therapy. However, you should be careful: exercises can not only improve, but also worsen the situation if they are done incorrectly. The main rule, which, unfortunately, is not always observed: exercise therapy should be done under the supervision of a doctor. At the very least, your doctor should conduct the first session to make sure you understand the instructions and are doing all the exercises correctly. Next, try to follow simple but mandatory rules:

JSC Family Doctor - Exercise therapy classes

2. You can’t exercise through pain. Fatigue and minor soreness as a result of the exercises done are normal. However, if movement when reaching a certain position causes pain, do not try to overcome it and continue moving.

3. The load should be increased gradually. The effect is achieved over time. You can’t make up for lost time by working out “properly.” You need to do exercises regularly and in a gentle manner. The intensity of exercise should be determined by a doctor. Do as many exercises as prescribed (no more). If it becomes painful, stop exercising. If pain occurs constantly during some exercise, then you will most likely have to give it up. Discuss this point with your doctor.

4. During exercise, make sure that both joints receive equal load. If you don’t pay special attention to this, most likely you will unload the problem joint by transferring the main force of support to the second one.

5. It is best to conduct classes at the same time. Treat exercise like a medicine, the intake of which is strictly regulated.

6. Maintain a measured pace, do not speed up.

Make an appointment Do not self-medicate. Contact our specialists who will correctly diagnose and prescribe treatment.

Weight loss

Obesity is a modifiable risk factor for the development of knee OA. Weight loss has been shown to reduce pain and improve joint function and stability without any side effects. There are many studies evaluating low-energy diets, exercise, or both for the treatment of knee OA.

When observing patients with diabetes and symptoms of deforming arthrosis of the knee joint and an average BMI of 37 kg/m2, the study had 2 groups: a group with stable weight and a group with weight loss for 1 year. Participants in the weight loss group lost 20 pounds and reported significantly better pain, function, and joint stability compared to those in the weight stabilization group. Significant improvements from baseline in pain, function, and joint stability were observed in patients with an average BMI of 42 and radiographic evidence of knee OA who underwent bariatric surgery. At one-year follow-up, the average reduction in BMI was 13 kg/m2.

Similar superior results were found in the diet plus exercise group among 316 participants with radiographic evidence of deforming knee arthrosis over 18 months compared with the lifestyle, diet only, and exercise only groups.

Based on the above studies, weight loss is a promising treatment for knee OA. It is a safe and effective way to improve knee pain scores, function, and range of motion without serious side effects. However, weight loss can be very challenging for obese patients with deforming knee arthrosis due to their limited mobility and lack of adherence to a low-calorie diet.

Symptoms of arthrosis

This disease usually first affects the knee joints, then spreads to the hip and shoulder joints. Arthrosis of the knee joint, the symptoms and treatment of which will be described below, is diagnosed, like other lesions, based on the results of radiography. In the picture you can see a reduction in the joint space and the presence of bone tissue damage. However, the results of radiographic examination do not always correspond to the clinical picture. In case of obvious pain, changes may not be expressed in the image, or vice versa - in the absence of pain, the image demonstrates obvious destruction of the joint tissue. Therefore, if necessary, other studies are prescribed: ultrasound, arthroscopy, MRI.

There are four main symptoms of arthrosis:

Pain. In most cases, pain is expressed during movement, usually its intensity is quite weak. For this reason, patients do not pay attention to this at first and the disease progresses. Over time, the pain becomes more pronounced; a person experiences it even with light exertion. Ultimately, in the absence of adequate treatment, pain also manifests itself at rest.
Crunch. When the joint wears out, a dry, characteristic crunch is heard when the surfaces rub. With further development of the disease it intensifies. It should be noted that if the sound is loud and the crunching is not accompanied by pain, we are not talking about arthrosis.
Reduced range of motion. Muscle spasms, reduction of the joint space, and the formation of osteophytes lead to stiffness of movement.
Modification of joints. The disease causes bone deformation and swelling caused by the accumulation of large amounts of fluid. Due to constant irritation of joint tissues, synovitis develops. It is worth noting that there is no point in pumping out the liquid without removing the cause of its excessive secretion.

With arthritis, pain does not depend on human movements and in most cases occurs at night. They should not be confused with arthrosis. Arthritic pain syndrome is more severe.

Intra-articular injections

Intra-articular injections for deforming arthrosis of the knee joint have been used for many years, and their effectiveness in modern literature is beyond doubt. However, some patients experience only minimal pain relief, while others have significant improvement within a few months. Despite variable long-term results, there is an increasing use of intra-articular injections for the treatment of knee OA, often with the goal of delaying total knee arthroplasty.

Corticosteroid (CS) and hyaluronic acid (HA) injections are the two main types of intra-articular injections available. More complex intra-articular injections, requiring specialized equipment and appropriate training of medical personnel, are platelet-rich plasma (PRP), stromal vascular fraction (SVF) and bone marrow concentrate (BMAC).

Corticosteroids provide relief 24 to 48 hours after injection, and injections may be repeated every 3 months as recommended by some authors. Patients with uncontrolled diabetes mellitus are not good candidates for CS injections due to acute increases in serum glucose levels. The best indication for the use of CS is synovitis of the knee joint, which is not controlled by taking NSAIDs. Evacuation of excess amount of synovial fluid from the joint followed by intra-articular injection of the CS significantly facilitates the range of motion in the joint, relieves pain and relieves inflammation well. The duration of the effect of the CS can last from several days to several weeks. Without additional treatment methods, one cannot count on a lasting effect from CS, because after the cessation of the drug effect, the symptoms of synovitis most often recur.

HA is a natural substance in synovial fluid and acts as a shock absorber for the knee joint, but with OA its qualitative and quantitative indicators deteriorate. Treatment of the knee with HA injections can be repeated every 3 months and can consist of a series of 1 to 5 injections given one week apart. HA provides protection to the cartilage covering of the bones in the joint, reduces friction, promotes the nutrition of chondrocytes (cartilage cells) and stimulates the production of its own hyaluronic acid. GCs do not have a direct analgesic effect, but pain reduction is achieved indirectly due to the above properties. Therefore, one cannot count on rapid relief of symptoms after injection of GC into the joint; it takes time for the full effect of the drug to develop.

When comparing CS and GC in studies, patients showed a sustained reduction in pain and improvement in range of motion in the joint over 3 months. It is worth noting that the effect of CS developed faster than when using GC. However, over time, the effect of CS decreased, while for GC, on the contrary, the effect persisted and gradually increased. An analysis of the studies found that CS may be beneficial in the short term and there is no evidence that the effect remains six months after a corticosteroid injection. Treatment results can be improved by combining the properties of CS and HA. In particular, use CS as the fastest way to relieve pain and synovitis, and then, after reducing swelling and inflammation, use GC to protect the joint and prevent exacerbations.

Physiotherapy and exercise therapy

In Western medicine, the concept of physiotherapist combines directly a physiotherapist and a physiotherapy doctor (physical therapy doctor). As methods of non-drug treatment of OA, both directions have a positive effect on the joints, alleviate the symptoms of the disease and quite logically complement each other. Situations often arise when a patient receives either a course of physiotherapy or a course of exercise therapy. And sometimes just one thing at all. It has been proven that the best results are achieved with the combined use of physiotherapy (EPT) and exercise therapy. The development of modern medical technology allows the use of the latest ERT methods, such as high-intensity laser (HILT), shock wave therapy (SWT), pulsed low-frequency electrostatic field (INESP), cryotherapy for the successful treatment of OA. Various portable devices are being created for independent use at home.

Physical exercises are increasingly taking first place in doctors’ recommendations for the treatment of arthrosis.

Explaining to the patient how to properly distribute his daily loads becomes the doctor’s primary task. When knee osteoarthritis is not adequately treated, people avoid physical activities, such as walking, that increase their pain. This is problematic because physical activity (exercise) is currently the most effective and safe non-surgical treatment for hip and knee osteoarthritis. More than 50 randomized controlled trials (RCTs) have shown that physical activity is effective in reducing knee , improving function, and preventing the development of severe mobility limitations compared with usual care, with a benefit-to-risk ratio greater than any other non-surgical knee treatment. Physical activity also reduces excess body weight and therefore reduces joint stress, joint stiffness, muscle weakness, depressed mood and motor coordination problems, and has a positive effect on lipid metabolism, hyperglycemia and systemic inflammation.

Research has shown that normalization of joint motion not only initiates local physiological mechanisms, but also involves central mechanisms acting on the spinal cord and brain, causing indirect analgesia through mobilization of the knee joint.

Regular exercise helps maintain a stable level of activity, preventing exacerbation of OA symptoms. The patient also gradually develops the ability to self-control and limits himself from excessive peak loads.

Decreased rates of compliance with physical therapy are thought to be a result of high time demands, activity-related pain, lack of transportation, and time commitments. Thus, cost issues are the main barrier to the use of ERT and exercise therapy. Physical therapy programs vary and should therefore be discussed by patients and physicians to improve treatment outcomes.

Degrees of arthrosis

Treatment of joint arthrosis depends on the degree of the disease. There are three stages, each characterized by its own symptoms and varying degrees of damage. Of course, therapy should be started at the first stage; ignoring the problem will lead to the need for endoprosthetics. There are arthrosis:

1st degree. Symptoms of the disease are weakly felt, slight pain is possible during exercise. At this stage, initial changes are observed in the synovial membrane, and the composition of the fluid changes. There is no modification of the muscles, but they are weakened.
2 degrees. The destruction of articular tissue begins, the formation of growths. There are noticeable but tolerable pains, crunching, and disruptions in muscle function.
2 degrees. The destruction of articular tissue begins, the formation of growths. There are noticeable but tolerable pains, crunching, and disruptions in muscle function.
3 degrees. The most severe stage, which is characterized by deformation of the joints, the axes of the limbs noticeably change. Motor function is greatly reduced, as the joint capsule becomes denser and the ligaments are shortened. There is chronic inflammation and constant severe pain. Trophic changes gradually spread to all tissues of the affected limb.

If rehabilitation is not started in time, after stage 3 the joint is completely destroyed, the only possible solution is endoprosthetics. Arthrosis of the shoulder joint and other types are characterized by complete immobility of the joint or, conversely, atypical mobility.

Fixation of the knee joint in an orthosis.

Knee orthoses are often used for osteoarthritis of the knee , and the American Academy of Orthopedic Surgeons recommends their use for biomechanical stability. Knee abnormalities associated with deforming arthrosis can cause significant pain and dysfunction, and knee orthoses have been shown to help maintain stability and function, especially in cases of unicompartmental arthrosis (damage to the outer or inner part of the joint). There are two types of orthoses that are commonly used for knee OA: relief and support. The unloading orthosis reduces pressure on the affected part of the joint, and the supporting one provides compression and stability of the joint during walking.

Fig.1. Unloading orthosis for the knee joint

Fig.2. Knee support orthosis

In a group of 204 patients with deforming arthrosis of the knee joints, after 26 weeks there was a significant improvement with the use of a load-bearing orthosis compared with no orthosis.

In a controlled study comparing weight-bearing orthoses and neoprene soft orthoses, at 6 months, significantly better results in pain levels after a 6-minute walk test and a 30-second stair climb test were reported in the weight-bearing orthoses group. When comparing patients with orthoses and without orthoses, significant differences were identified in WOMAC function indicators (the WOMAC test is a 24-question questionnaire for the patient to fill out independently).

36 patients with Kellgren-Lawrence grade 3-4 knee arthrosis were randomized to receive a pneumatic relief orthosis in conjunction with conventional treatment or just conventional knee treatment . At one-year follow-up, there were significantly fewer patients receiving injections (46% vs. 83%) and fewer subsequent knee replacements in the orthosis group (18% vs. 36%).

Based on these data, orthoses reliably help patients with knee OA achieve significant pain reduction, improved function, and may delay the time to joint replacement. This is a non-drug treatment option that can improve symptoms and limit the use of other treatments that carry more risks.

Conclusion

Deforming arthrosis of the knee joint is a chronic disease that is often difficult to treat and creates significant difficulties for affected patients. It is critical for clinicians to understand a patient's goals, comorbidities, severity of OA, and the effectiveness of treatment options to determine what is most beneficial for the patient. NSAIDs, weight loss, intra-articular injections, exercise therapy, and physical therapy have been shown to be effective nonsurgical treatments for knee OA. Knee bracing is a non-invasive, non-pharmacological option that can significantly reduce pain and improve function without any side effects. Therefore, based on the above, knee orthoses in combination with other non-surgical treatment methods should be one of the main treatment options to reduce pain, improve function and stability of the knee joint in OA.