Patient Specific Treatment for Arthritic Knee Pain
Steve Mora MD,
Knee and Shoulder Specialist at Restore Orthopedics and Spine Center, Orange County
Treating arthritic knee pain is not always straight forward. One of the reasons is we do not always know how or why the arthritis is causing knee pain. Confounding the problem is the fact that many patients have arthritic looking knees on X-ray but have no pain. This observation is both perplexing and at same time promising. It seems like the only two options offered by some physicians is either a steroid injection or total knee replacement. There is actually a lot more to the treatment of knee arthritis than these two options.
Why does arthritis cause pain?
Painless arthritic knees may be attributed to the knee joint successfully adapting to the degeneration and wear. Arthritis causes many pathological changes in and around the joint. Pathological changes include thinning or ulceration of the cartilage, deformity, meniscus tearing, joint fluid thinning, mal-tracking, loose cartilage, deformity of the limb, and inflammatory reactions within the joint. Our bodies will attempt to compensate and adapt to these changes. Adaptive changes can effectively occur over a long period of time. At some point there will be failure of adaptation and or tissue mechanical failure.
For example, when the joint cartilage starts to thin and wear down (hallmarks of arthritis) the surrounding bone will adapt by becoming harder (sclerotic) or even bigger (spur formation). Our musculoskeletal system is dynamic and constantly changing. It responds to stress. One example of adaptation is spur formation. The spur which grows next to a joint is essentially an extension of the joint surface, caused by the increased load to the bone, which helps to relieve the increased joint stress. These spurs are a sign of the arthritic process but not necessarily the cause of the pain. They are present usually before the patient experiences pain. There are times when the spur can be the actual problem causing the pain; however, usually it is not. By broadening its joint surface, our bodies attempt to adapt to the pathologic changes. Unfortunately not all knees can adapt well enough, long enough, or fast enough.
Arthritis has many different “personalities”.
Arthritis can present with knee inflammation and pain. It is thought to be due to our body responding to the degeneneration and increased forces on the cartilage. Unfortunately the inflammatory process becomes can become the main painful issue. An insidious process will take place which includes worsening pain along with worsening stiffness. As the stiffness worsens the pain will also worsen. It becomes a downward spiral. Patients with early stiffness and pain might respond to measures to relieve inflammation such as steroids, platelets, rest, ice, etc. If the stiffness or loss of motion is not addressed efficiently the pain will return. This group of patients does very well with physical therapy after the inflammation is curtailed.
Knee arthritis also causes narrowing of the joint space. When narrowing occurs, it will lead to increased pressure on the meniscus. The meniscus is a little pad within the space situated in between the bones. The meniscus will become shredded (degenerative meniscus tear) or even pushed out (extruded meniscus) of the space. Once the meniscus fails, it leads to worsening pressure on the underlying bone. In some cases, focusing treatment only on the degenerative meniscus tear might help to some degree, but the underlying problem is actually the narrowing and worn out joint surface. This situation is very common. I have operated on many degenerative meniscus tears by doing a simple arthroscopic clean up surgery. This approach will sometimes help but will often disappoint. These patients need more than a simple arthroscopic clean up. The key is to try to figure out if the pain is stemming from the torn meniscus fragments, cartilage flap or from the increased stress on the bone and cartilage. This is not easy and sometimes not possible to separate. Sometimes patients will opt to do the cleanup type of arthroscopic surgery; however, they need to be counselled about needing more treatment after the arthroscopy with various types of injections (Hyaluronate, PRP, Adult Stem Cells), physical therapy, and bracing. Some of these patients have progression of the arthritic pain and will require a partial or full knee replacement.
One of my approaches for patients with arthritic knee pain and MRI showing degenerative meniscus tears is to:
1) First do arthroscopic surgery to clean up loose torn meniscus fragments. This step is done to remove painful catching. In some cases I will do abrasion chondroplasty. Abrasion chondroplasty is done at the time of arthroscopy. It can help to cover small areas of exposed bone with a thin layer of repair cartilage.
2) When the patient recovers from the arthroscopic surgery I will do a Adipose Based Adult Stem cell procedure called LipoGems. Lipogems is essentially a specialized adipose tissue (fat) injection which serves two purposes, one is to provide an instant and long lasting cushion and secondly to provide stem cells which secrete anti inflammatory cytokines and growth factors which will reduce the painful inflammatory effects of arthritis. The adipose harvest is done in a similar way as liposuction however the goal is to harvest just enough fat tissue for the arthritic joint. I’ve personally had an very high success rate using this approach. The pain relief from the Lipogems can last 1-3 years. This approach is especially good for patients who’ve been told they have “bone on bone arthritis.
Another problem associated with arthritis of the knee is progressive angulation. Some patients with arthritis will develop bowing (varus) or a knock knee (valgus) deformity of the leg. As the bowing progresses, it continues to put more pressure on the bone, usually only on one side of the knee. If the joint cannot adapt fast enough the supporting bone under the area of greatest pressure fails or fractures. This situation will show up on an MRI as bone marrow edema directly under the arthritic joint. The pain from bone edema related to arthritis usually comes on abruptly. The edema is localized to the bone just under the arthritic cartilage; it’s the area under the highest load. It’s very interesting that bone marrow edema associated with arthritis looks identical to fatigue fractures seen in endurance runners. Because there is technically not a fissure or a crack in the bone, physicians, including radiologists, rarely describe it as a fatigue fracture in patients with arthritis, but in its purest form it looks and acts like a fracture, so it should be treated as fatigue fracture. This unique arthritic situation can be treated by reducing the force upon the knee with rest, bracing, and weight loss. Further treatment might include a new minimally invasive surgically procedure called subchondroplasty. This is a calcium based bone substitute paste which is injected into the bone’s edema. The injected calcium paste will harden and provide support for the fractured bone. This treatment can be compared to adding a stronger concrete foundation under an aging home. The subchondroplasty procedure takes about 2 months to heal. An MRI of the knee is necessary to determine if a patient is a candidate for this procedure. You can obtain information about the suchondroplasty procedure at http://www.subchondroplasty.com/. This procedure is very helpful in reducing pain for patients who’ve been told they have arthritis associate with a “bone bruise” on MRI.
When I evaluate patients with knee pain related to arthritis, my goal is to understand the actual cause of the pain. It takes time to understand the pain pattern, onset, location of pain etc. It also takes good X-rays and usually an MRI to understand the severity of the arthritis and get a better idea of what is causing the pain. In some cases patients will do well with losing a modest amount of weight and wearing a brace. I will refer patients to the St. Joseph Hospital Wellness program to help with this. Some patients also do very well with one or two steroid injection. Others require a multi-modal approach which might include minimally invasive arthroscopic surgery to clean up loose debris and then Regenerative Medicine injections to stimulate healing, provide a cushion, to release natural growth factors and anti inflammatory cytokines. Regenerative Medicine treatments can include: Platelet Rich Plasma (PRP), bone marrow concentrate (BMC), adipose tissue derived cells (LipoGems) and Hyaluronate to stimulate healing. Patients with acute bone marrow edema (fatigue fracture) can do well with arthroscopy and a subchondraplasty procedure described above.
Other patients with advanced degeneration and who do not respond to conservative treatment, might do very well with a partial knee replacement. Partial knee replacements can offer long tern pain relief when done on patients with arthritis limited to one area of the knee. Some patients will do best with a total knee replacement.
Every patient with arthritis is different. This is why the approach for treating arthritis is patient and disease specific. Patients should be educated about the complex arthritic process and that there is no single magic bullet; but there is hope. The hope comes in form of knowing their pain and function can be improved. It just might take time to figure it all out. It also takes a patient doctor and a patient patient. I hope this information helps. Please let me know if I can be of service.
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He received his medical education at UC Irvine College of Medicine where he finished in the top of his class earning the coveted AOA Medical Society honors. He completed his Orthopedic Surgery training LAC+USC Medical Center and then did a additional Sports Medicine Fellowship at the Santa Monica Orthopaedic and Sports Medicine Group where focused on sports medicine, shoulder, knee, hip arthroscopy. He has published numerous book chapters on the topics of ACL injuries in soccer players, cartilage restoration, and athletic hip injuries. He is currently practicing Orthopedic Surgery in the City of Orange Orange County. He is a founding partner at Restore Orthopedics and Spine Center (www.restoreorthopedics.com). Dr. Mora’s practice focus is on sports related trauma, MMA injury treatment, arthroscopy of the shoulder, hip, knee and elbow, and partial and total knee replacement. He sees athletes of all levels including professional soccer and UFC/MMA patients. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
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Restore Orthopedics and Spine Center
112o W. La Veta Ave, Third Floor
Orange, CA 92868
Office: (714) 598-1745
Fax: (714) 941-9539
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