Written by Teo Buzas, PT, DPT
Osteoarthritis (OA) is the most common disorder of the musculoskeletal system, with hip and knee joints being among the most frequent involvement (1). OA has been and continues to be labeled as “wear and tear.” Fortunately, that is starting to change. What if OA is NOT wear and tear? It is not that straightforward.
Yes, in OA some changes happen to the joint, but this does not mean it is always due to wear and tear, and it does not mean you will have pain. The three main clinical features of osteoarthritis include pain, stiffness, and decreased strength.
Our understanding of OA has advanced dramatically. This is no longer a cartilage-centric disease and archaic terms such as wear and tear and degenerative are now considered both pejorative and inaccurate (2). OA is best characterized as a disease with chronic abnormal bone remodeling affecting the entire joint.
It is important to know that imaging findings of OA correlate very poorly with symptoms. Many people see arthritic-like changes on imaging without any symptoms. So, how often do we find knee “osteoarthritis,” on MRI, in uninjured and asymptomatic adults? A systematic review of 5397 knees gathered from 63 studies found (3):
- In adults younger than 40 years old, the prevalence of OA features was found in up to 14%.
- In adults older than 40 years old, the prevalence of OA features was found in up to 43%.
So, physical osteoarthritic features may increase the likelihood of developing pain. But it does not guarantee you will have pain or how much. That is because it is impossible to see pain on imaging.
What about in osteoarthritis in athletes?
MRI scans of 35% of collegiate basketball players with NO knee pain show SIGNIFICANT abnormalities (4).
Do you need surgery?
What if sham surgery works just as well as arthroscopic surgery for knee OA? 180 people participated in a controlled trial of arthroscopic knee surgery for knee OA (5). 61 were assigned to a lavage group, 59 to arthroscopic debridement, and 60 to the sham surgery group. In the lavage group, the joint was flushed with fluid to wash out loose tissues/debris. In the arthroscopic debridement group, the rough cartilage on the bones was shaved away, and torn/degenerative tissue at the meniscus was removed. The joint was also flushed with fluid. In the placebo (sham) group, three 1 cm incisions were made on the skin, after which the surgery was conducted as if it was happening. The outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.
What about total knee replacement?
Five misconceptions found in individuals pursuing total knee replacement surgery:
- Pain is a sign that damage is occurring to the joint.
- Osteoarthritis is always caused by wear and tear.
- Loading an arthritic joint is dangerous for the joint surfaces.
- Physical therapy and exercise cannot replace worn out cartilage, so there is no point in doing it.
- Joint replacement is the only way to fix osteoarthritis and cure pain.
A study from 2014 (6) used a validated algorithm to judge the appropriateness of total knee arthroplasty in the US. They found that approximately 1/3 of total knee arthroplasty surgeries were judged to be inappropriate.
Have you tried:
- Getting the best information and education on your condition and what you can do for it?
- Incorporating an exercise routine into your lifestyle consistently?
- Increase enjoyable physical activities?
- Weight loss?
It is recognized that treatment choices provided for patients needs to swing from drugs and surgery to empowered management with a focus on participation in desired activity through exercise and self-management. The FOCUS should be placed on what you CAN DO.
In some cases, surgery can play a very important role.
People who may benefit from a total knee replacement:
- Experiencing joint symptoms (pain, stiffness, and reduced function) that have a profound impact on quality of life.
- Have tried (and persisted with) the best non-surgical treatments (exercise, weight loss, lifestyle modification) and have not experienced improvement.
Beliefs and knowledge affect our behavior, and therefore, our outcomes. Consider one case from research undertaken to understand the experiences of individuals pursuing total knee replacement. One woman, waiting to get a knee replacement, spoke with the researchers as part of this study.
She did not know she had knee OA until she saw her primary care physician. She was referred to get a scan for a different reason and had incidental findings on the scan that showed changes consistent with OA in her knee. This information was presented to her.
She watched family members suffer from OA and was afraid of going down the same path. So, she made substantial changes in her life. She cut down on exercise, avoided using the stairs and squatting because these were activities, she thought, that would increase loading through the knee. She thought of her condition as wear and tear. She thought loading was bad. She avoided many activities that would help to improve her function and decrease pain.
She went back to her primary care a few years later and had a follow-up scan. In her words, she now had “bone on bone.” She then felt that a knee replacement was inevitable. However, she was told that she was too young for a joint replacement, so she just waited it out. She stopped doing the things she loved. She was getting depressed, she was stressed financially, and she was not sleeping well. This went on for years. She put her life on hold in waiting for this “cure.” This approach made things worse.
When you stop doing the things you love and value, it has consequences on your mental and physical health. What was missing from her story were any empowering messages and treatment options for her knee and pain. There are too many cases like these where people don’t know and understand how much they can do to improve their pain and function.
What about exercise?
Appropriate physical activity, exercise, and guided progressive loading of the tissues are good for osteoarthritis. We have seen this in the research for years (7, 8). It has been found that moderate exercise does not lead to an acceleration of knee osteoarthritis. Further, there appears to be improved physical functioning and reduction of pain and disability in those who exercise (9). Should you stop impact/running activities? Typically, the answer has been yes. But does it have to be?
A study from 2019 looked at the short-term impact of long-distance running on knee joints using MRI. 83 participants completed a marathon, and they found that the main weight-bearing parts of the knee with subchondral bony oedema before the marathon, in asymptomatic middle-aged adults, showed reversibility following the training for and completion of running a marathon. Furthermore, marathon running did not result in the progression of meniscal tears, and their presence did not affect performance. This evidence makes us question impact activity (marathon running) and knees joint health (10).
What about strength/resistance training?
A systematic review from 2020 (11) looked at determining whether resistance training affects pain and physical function in patients with knee OA. Their major finding was that large and medium effect sizes were related to both decreased pain and improve physical function.
So, what can, and should, you do?
Physical therapy (PT) is one of the cornerstones for the conservative management of hip or knee OA. A clinical practice guideline, updated in 2020, investigated the best treatments for both hip and knee OA. Here is what they found: “Based on the likelihood of the effects, the limited side effects, the demonstrated cost-effectiveness, and a high acceptability of exercise therapy, the guideline panel believes that the intervention can be strongly recommended.” (12). The clinical effect of PT on pain and disability in hip or knee OA is substantial (13).
The pillars of conservative management of osteoarthritis:
- Exercise and activity
- Weight loss
- Lifestyle change
Also, remember that health is multidimensional. What else can you do to be healthier?
At Bridging the Gap Physical Therapy, we are here for you. We offer full body evaluations and discuss your treatment plan. This includes your diagnosis, your goals, and the plan for getting you there. Find out more by speaking to our team today at 239-676-0546.
- Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. Lancet, 393, 1745–1759.
- Hunter DJ. Osteoarthritis: time for us all to shift the needle. Rheumatology. 2018;57(4):iv1–iv2.
- Culvenor AG, et al. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med 2019;53:1268–1278.
- Major NM, Helms CA. MR imaging of the knee: findings in asymptomatic collegiate basketball players. AJR Am J Roentgenol. September 2002;179(3):641-644.
- Moseley JB, et al. A controlled trial or arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347(2):81-88.
- Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol 2014;66(8):2134-2143.
- Minor MA, Webel RR, et al. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis and Rheumatology. 1989;32(11):1396-1405.
- Ytterberg SR, Mahowald ML, Krug HE. Exercise for arthritis. Baillière’s Clinical Rheumatology. 1994;8(1):161-189.
- Bosomworth NJ. Exercise and knee osteoarthritis: benefit or hazard? Can Fam Physician 2009;55:871-8.
- Horga LM et al. Can marathon running improve knee damage of middle-aged adults? A prospective cohort study. BMJ Open Sport & Exercise Medicine 2019.
- Turner MN et al. The Role of resistance training dosing on pain and physical function in individuals with knee osteoarthritis: a systematic review. Sports Health. 2020;12(2):200-206.
- Van Doormaal MCM, Meerhoff GA, Vliet Vlieland TPM, Peter WF. A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis. Musculoskeletal Care. 2020;18(4):575-595.
- Fransen, M., McConnell, S., Harmer, A. R., Van der Esch, M., Simic, M., & Bennell, K. L. (2015). Exercise for osteoarthritis of the knee: A Cochrane systematic review. British Journal of Sports Medicine, 49, 1554–1557.