Osteo-arthritis of the knee – Case Study 15.
Mrs D, a 56 year old ITU nurse, presented to the clinic with a two month history of pain and restriction of movement of her right knee. She explained that it was most likely an acute flair up of her knee osteo-arthritis that was first diagnosed on X-ray three years before during a similar episode. Her GP had informed her that the X-ray report had suggested mild to moderate osteoarthritis and prescribed a course of Non-steroidal anti-inflammatory drugs (NSAIDs) and rest.
On that occasion the pain took four weeks to completely settle down. She explained that despite returning to her GP for a further prescription of NSAIDs her symptoms had not settled down this time and following a review of her condition her GP then had placed her on the waiting for Physiotherapy.
In addition Mrs D’s GP had insisted she take some time off from work and signed her off for two weeks but she felt obliged to return after one week due to staff shortages in her department.
Mrs D was convinced that many of her problems were work related.
Her role in ITU required her to stand for much of a 12 hour shift and she felt this was aggravating her symptoms. As is the case she received wide ranging advice from friends, family and colleagues. One of her colleagues suggested applying an elastic tubi-grip support to her knee. She persevered with it for several days but found it offered no support and only served to cut off the circulation to her leg. Another suggested consulting an Osteopath.
Physical examination and orthopaedic tests served to confirm the radiological findings of osteo-arthritis. The Range of Motion (ROM) in the right knee had decreased to 110 degrees of flexion with a painful end range (with a pain score of 7/10). There was tenderness along the joint margin and evidence of some swelling.
Although Mrs D was not aware of any pain or restriction in her left knee on examination it demonstrated early signs of osteo-arthritis. ROM had decreased to 130 degrees of flexion with mild pain at the end range (with a pain score of 2/10).
Treatment and Management
Mrs D received 6 treatments over a period of 10 weeks. This involved hands on osteopathic treatment, tailored exercise prescription, dietary / supplementation and lifestyle advice.
At the end of this period she stated that her mobility had greatly improved. She was much more comfortable overall and her pain score was down to 3/10 for her right knee and 1/10 for her left knee.
What happens to a knee with osteo-arthritis?
• The surface of the cartilage becomes thin and rough.
• The bone immediately beneath the cartilage may start to appear like pot-holes.
• There may be active inflammation as the body attempts to repair the damage.
• Bony spurs (or osteophytes) form around the circumference of the joint.
• The synovium, that contains the synovial fluid around the joint, may swell and produce excess fluid, causing it to swell.
• The outer capsule and ligaments may thicken and eventually contract.
Who Gets Osteoarthritis of the Knee?
• 4.11 million people in England are believed to have osteo-arthritis of the knee (that’s approx. 18% of the population aged 45 years old and over).
• Women are more likely to have osteoarthritis than men.
What are the causes of Osteoarthritis of the Knee?
There is no single cause for OA. But there are several risk factors that increase the likelihood of you suffering it. For example:
• Age: Your risk increases over the age of 45.
• Gender – women are more likely to suffer knee OA.
• Obesity: for every pound of weight gained it adds 3 to 4 pounds of strain on the knees.
• Heredity. This may include genetic mutations that can increase susceptibility to knee OA or abnormalities of the bones or lack of stability of the connective tissue around the joint.
• Injury: either an acute event or long term exposure that causes gradual deterioration.
Signs & Symptoms in Knee Osteo-arthritis.
• Generally develops slowly.
• Initially pain and stiffness in morning or inactivity.
• Your knees may hurt when you stand up from a seated position, kneel or go upstairs.
• This may progress to causing pain when walking or simply sitting down.
The knee may become swollen and inflamed periodically. Initially this may respond to over the counter NSAIDs but over time you may experience chronic inflammation that doesn’t improve with these drugs.
Popping or Cracking
You may become more aware of pops, cracks and grinding coming from your knee. They may indicate that you have lost some of the joint cartilage or bony spurs fractioning off each other.
Giving way and locking
On what may seem like a random event a loose body within the knee joint can cause it to lock up or give way.
Deformities of the Knee
As the condition progresses you may start to notice physical changes. The knee may look sunken as you lose tone in the surrounding musculature. They may look ‘knock kneed or bowed’ although many severely affected knees may look relatively normal.
Decreased Range of Motion (ROM)
Again this is generally a slow process and increasingly you become aware that you now have limitations. Stages of Knee Osteoarthritis
Knee experts classify Osteoarthritis of the Knee in several ways. Some use a scale from 1 (mild) to 4 (severe) whereas others prefer to characterize it as either mild, moderate or severe.
Degrees of Arthritis
Mild Osteoarthritis of the knee – the surface of the cartilage will have begun to wear. You may experience mild pain and stiffness in the morning.
Moderate OA of the knee – the cartilage continues to disintegrate. The joint fluid starts to lose its capacity for shock absorption. You may notice the presence of bony spurs (osteophytes) on the bone edge. It may be painful when you move.
Severe OA of the knee – may be complete erosion of the knee cartilage causing the bones to friction together. Pain is probably more constant and intense by this stage affecting everyday activities.
Drugs for osteoarthritis of the knee
• Painkillers – (analgesics) help with pain but will not affect the actual process of arthritis. Generally sufferers start with milder painkillers like Paracetamol. They may progress to stronger painkillers (Co-codamol & Tramadol) These are generally prescription only and may also come with potential side-effects (like nausea, constipation and dizziness).
• Non-steroidal anti-inflammatory drugs (NSAIDs) – e.g. Ibuprofen or Naproxen. Particularly helpful if inflammation is contributing to your pain.
• NSAID creams or gels are another alternative if there’s a reason you can’t take tablets.
Osteopathy or Physiotherapy for Knee Osteo-arthritis.
• Can provide hands on treatment to help gently mobilise joints and relax tissue. We use a variety of techniques including massage and acupuncture.
• They can also provide an exercise program to both help strengthen muscles around joints and improve mobility.
• Many are also able to provide lifestyle, dietary advice, information about hydrotherapy and supplement advice.
Steroid Injections for Knee Osteo-arthritis.
These may start working within a day or two and can improve symptoms for weeks or months.
Hyaluronic Acid Injections
Hyaluronic acid is similar to a substance that naturally occurs within the joints. It serves the dual role of lubricant and shock absorber in the joints. This therapy isn’t used widely as organisations like the National Institute for Health and Clinical Excellence (NICE) have not been convinced of its effectiveness.
Transcutaneous electrical nerve stimulation (TENS)
This small electronic device is used by chronic pain sufferers and is thought to help modulate the pain experience although research suggests that it doesn’t work for everyone.
These are becoming increasingly popular employing state of the art materials and design. More and more evidence is being collected to suggest that certain models could potentially help to improve daily activities.
Surgery Knee Osteo-arthritis
• Arthroscopy – this may involve washing out loose fragments of bone or trimming, and/or repair of tissue within the joint.
• Partial Knee Replacement (PKR) – as the name suggests only one side of the joint is replaced. This operation offers a shorter hospital stay and overall recovery time.
• Total Knee Replacement (TKR) – in this case both sides of your knee joint are replaced. Replacements now last on average over 15 years.
References & Links