Osteoarthritis Of The Knee

  • Salma Tarabeih Pharm.D. Clinical Pharmacist | Pharmacy Preceptor, Beirut Arab University
  • Geethaa Sathveekan Bachelor of Medicine, Bachelor of Surgery - MBBS, Queen Mary University of London

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Are you acquainted with knee osteoarthritis? If so, what characterises this condition? What strategies exist for treating and preventing it? This article will explore these questions and unravel intriguing insights on the topic. Let's dive into the details and enjoy the read!

What is knee osteoarthritis?

Knee osteoarthritis, also called degenerative joint disease, is typically caused by wear and tear and continuous loss of articular cartilage (Figure 1). It is most frequent in the elderly. Knee osteoarthritis can be categorised into two types, primary and secondary.1

The strength of the clinical symptoms may differ for each individual, however, they usually become more severe, frequent, and incapacitating over time. The rate of progression also varies for each patient, but in some cases, osteoarthritis may ultimately lead to disability.1 

Figure 1: Osteoarthritis often results in bone rubbing on bone.2 

Causes of knee osteoarthritis

As previously mentioned, knee osteoarthritis can be divided into two classes primary and secondary, depending on its cause. Primary knee osteoarthritis is caused by articular cartilage degradation without any known reason, typically attributed to factors such as age and wear and tear.1 

Secondary knee osteoarthritis is the result of articular cartilage degeneration due to a known reason. These may include:

Risk factors

Concerning the risk factors for knee osteoarthritis, some of them can be modified such as:1

Nonetheless, there are other factors predisposing to this condition which cannot be changed. These include:1

  • Gender: osteoarthritis is more common in females
  • Age: osteoarthritis is more common in the elderly
  • Genetics
  • Race: African Americans are more prone to develop symptomatic knee osteoarthritis compared to other races3 

Clinical presentation

Knee symptoms can vary depending on the cause of the problem. The most common symptom of knee osteoarthritis is pain across the knee joint. Pain can be dull, sharp, persistent, or sporadic (on and off). Pain can vary from mild to distressing.4 

The range of motion of the knee joint can be decreased. On examination, the physician may hear grinding or cracking sounds and may describe muscle fragility. Swelling, locking, and giving way of the knee are common complicated symptoms. 

These disabilities, mainly linked to pain, are usually expressed by difficulty walking, climbing stairs, carrying out household tasks, and sitting straight. Such dysfunctions have a negative psychological effect, which can result in a reduced quality of life.4 

Knee pain can develop slowly and progress over time, or may have an abrupt onset. Pain and rigidity in the morning, after sitting, or after extended rest are most common. Over time, painful symptoms may happen more frequently, including during rest or at night. Typically, pain flares up with powerful activity. Joint pain and stiffness after sitting or prolonged rest usually ease within less than 30 minutes.4 

Diagnosis

The early identification of patients with knee osteoarthritis and the correction of risk factors is paramount. Before the physician can establish a clinical diagnosis of primary knee osteoarthritis, secondary underlying disorders should be considered and eliminated.4 

A clinical diagnosis of knee osteoarthritis is confirmed by the presence of usual symptoms, physical examination findings, laboratory results, and imaging features. No single clinical feature is definitively sensitive or specific. Generally, the more features that exist, the more probable the diagnosis is.4 

A diagnosis of knee osteoarthritis can also be made through the utilisation of the American College of Rheumatology criteria, as well as EULAR diagnostic criteria. Using the latter criteria, the identification of three symptoms (constant knee pain, restricted morning stiffness and reduced function), and three signs (crepitus, limited movement and bony enlargement) can correctly diagnose 99% of knee osteoarthritis when all six symptoms and signs are present.5 

Blood tests may be ordered to eliminate secondary causes. Some of the common initial studies that are ordered include complete blood cell count with differential, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor titers, and evaluation of synovial fluid.

Management

Treatment for knee osteoarthritis can be divided into non-surgical and surgical management. Initial treatment starts with non-surgical methods and moves to surgical treatment once the non-surgical approaches are no longer efficacious. There is a broad range of available non-surgical methods for the management of knee osteoarthritis, which may not change the underlying disease process, but can substantially decrease pain and disability.1 

Knee osteoarthritis (OA) is best managed by an interprofessional team that comprises an orthopaedic surgeon, rheumatologist, physical therapist, dietitian, pain specialist, internist, nursing staff, physical therapist, and pharmacist.

Conservative treatment (non-surgical)

Non-pharmacological therapy

The first-line therapy for all patients with symptomatic knee osteoarthritis includes patient education and physical therapy. An integration of supervised exercises and a home exercise program has been shown to produce the best results. These benefits disappear after 6 months if the exercises are discontinued. The American Academy of Orthopedic Surgeons endorses this treatment.

Weight loss is invaluable in all stages of knee osteoarthritis. It is recommended in patients with symptomatic arthritis with a body mass index above 25. Weight loss is best achieved through diet control and low-impact aerobic exercise.

Another option that may help with knee pain is the use of knee braces. Knee bracing in osteoarthritis includes unloader-type braces that move the load away from the involved knee compartment.1 

Medications

Various types of painkillers are used in knee osteoarthritis management and their selection is based upon multiple factors.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a diverse group of substances that share similar therapeutic effects and side effects. For osteoarthritis, orally administered NSAIDs are commonly prescribed, encompassing various doses and formulations. However, the oral intake of these medications poses significant cardiovascular, gastrointestinal, and renal risks

To mitigate these risks, topical NSAIDs have gained popularity for alleviating osteoarthritis pain due to their comparatively lower risk profile compared to oral preparations. Several guidelines recommend the use of topical agents in osteoarthritis management.

  • The effectiveness and safety of opioid oral therapy has given rise to some concerns over their use. In addition to NSAIDs, opioids have a similar action in mitigating pain in osteoarthritis patients. Nevertheless, their painkiller effect is limited and they produce frequent side effects which are severe in certain cases with long-term use
  • Platelet-rich plasma (PRP) is a novel option used to stimulate injured cartilage regeneration. New findings show that using PRP injections for knee issues, specifically in mild to moderate osteoarthritis, seems to be helpful. Patients experience less pain, stiffness, and better knee function. However, there is insufficient evidence to support the use of PRP as a treatment option
  • Glucosamine and chondroitin sulfate are widely available as dietary supplements. They are structural components of articular cartilage, and therefore it is thought that consumption of these supplements can improve the overall health of the articular cartilage

Nonetheless, the existing evidence is not strong enough to say that these supplements are beneficial in knee osteoarthritis. There are no major drawbacks to taking the supplement. If the patient understands the evidence behind these supplements and is willing to take the supplement, it is a relatively safe option. However, it is possible that any benefit gained from supplementation is due to a placebo effect.1 

  • Intra-articular corticosteroid injections may be beneficial for symptomatic knee osteoarthritis, particularly where there is a significant inflammatory component. Injecting the corticosteroid into the knee can help decrease inflammation caused by osteoarthritis and lower the overall impact of the steroid on the body, thereby reducing side effects
  • Intra-articular hyaluronic acid is a further injectable option for knee osteoarthritis. Hyaluronic acid is a complex carbohydrate molecule found throughout the human body and is a vital component of synovial fluid and articular cartilage. Hyaluronic acid is broken down during the process of osteoarthritis, contributing to the loss of articular cartilage which manifests with stiffness and pain. The delivery of hyaluronic acid locally into the joint acts as a lubricant and may help raise the natural production of hyaluronic acid in the joint. Although this treatment option is prevalent, it is not highly endorsed in the literature

Surgical treatment

Surgery options may involve:1

What information should a patient be aware of?

Patient education focuses on both non-pharmacological and medication-based approaches. Non-medication approaches include weight loss, bracing to correct joint alignment, exercise and physical therapy, and support groups. Medication compliance needs to be highlighted; sometimes, patient adherence diminishes due to the presence of unpleasant side effects. Patients be informed that osteoarthritis lacks a cure and there is potential for disease progression, especially if they do not adhere to the recommended treatment guidelines.1 

Summary

Knee osteoarthritis, or degenerative joint disease, is primarily caused by wear and tear on articular cartilage and is common in the elderly.

It can be classified as primary (age-related) or secondary, with symptoms worsening over time.

  • Primary osteoarthritis results from age-related cartilage degeneration, while secondary osteoarthritis has identifiable causes

Risk factors include articular trauma, occupation, muscle weakness, weight, health, gender, age, genetics, and race.

Symptoms vary but commonly include knee pain, reduced range of motion, muscle weakness, swelling, and joint instability.

  • Symptoms may worsen over time, impacting daily activities and quality of life

Early recognition is crucial, ruling out secondary causes before diagnosing primary knee osteoarthritis.

  • Diagnosis involves assessing symptoms, physical examination, laboratory tests, and imaging

Treatment for knee osteoarthritis involves both non-surgical and surgical approaches.

  • Non-surgical management is typically initiated first and progresses to surgical treatment if non-surgical methods become ineffective

    Conservative (non-surgical) treatment includes:
  • Non-medication therapy such as patient education, supervised exercises, home exercise programs, and weight loss
  • Medication therapy involves NSAIDs, opioids, platelet-rich plasma (PRP), glucosamine/chondroitin sulfate supplements, intra-articular corticosteroid injections, and intra-articular hyaluronic acid injections
  • Surgical treatment options include osteotomy, unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA)

Patient education should emphasises both non-pharmacological and drug-related approaches, and acknowledge the chronic nature of knee osteoarthritis and the importance of treatment adherence.

References

  • Hsu, Hunter, and Ryan M. Siwiec. “Knee Osteoarthritis.” StatPearls, StatPearls Publishing, 2023. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK507884/.
  • Arthritis of the Knee - OrthoInfo - AAOS. https://www.orthoinfo.org/en/diseases--conditions/arthritis-of-the-knee/. Accessed 21 Nov. 2023.
  • Primorac, Dragan, et al. “Knee Osteoarthritis: A Review of Pathogenesis and State-Of-The-Art Non-Operative Therapeutic Considerations.” Genes, vol. 11, no. 8, July 2020, p. 854. PubMed Central, https://doi.org/10.3390/genes11080854.
  • Lespasio, Michelle J., et al. “Knee Osteoarthritis: A Primer.” The Permanente Journal, vol. 21, Sept. 2017, pp. 16–183. PubMed Central, https://doi.org/10.7812/TPP/16-183.
  • Heidari, Behzad. “Knee Osteoarthritis Diagnosis, Treatment and Associated Factors of Progression: Part II.” Caspian Journal of Internal Medicine, vol. 2, no. 3, 2011, pp. 249–55. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770501/.
  • Uivaraseanu, Bogdan, et al. “Therapeutic Approaches in the Management of Knee Osteoarthritis (Review).” Experimental and Therapeutic Medicine, vol. 23, no. 5, May 2022. www.ncbi.nlm.nih.gov, https://doi.org/10.3892/etm.2022.11257.[7]:Shahid, Abbas, et al. “Do Platelet-Rich Plasma Injections for Knee Osteoarthritis Work?” Cureus, vol. 15, no. 2, Feb. 2023. www.ncbi.nlm.nih.gov, https://doi.org/10.7759/cureus.34533.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Salma Tarabeih

Pharm.D. Clinical Pharmacist | Pharmacy Preceptor

Salma is a Doctor of Pharmacy with several years of experience in Pharmacy Management and Patient Consultation. She has a track record of delivering remarkable patient care and optimizing drug therapy outcomes. Her expertise includes guiding students, collaborating with healthcare professionals, and ensuring quality standards. She is passionate about Clinical Research and Pharmacy Practice Education, and she is dedicated to making a positive impact in these areas.

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