This article is a transcribed edited summary of a video Bob and Brad recorded in February of 2022. For the original video go to https://www.youtube.com/watch?v=Kfo4bwTQiIk
Brad: We've got Chris here. He's done I don't know how much research on this topic with knee replacements and what you need to know if you've got a knee that's questionable. Do you need it replaced or what are the options. It's all going to be answered right here. Chris, I'll let you take it away, I'm going to give some advice on the exercises and stuff I know a lot about, in here too.
Chris: All right, well, today we're talking about osteoarthritis of the knee.
Brad: Osteoarthritis, that's different than rheumatoid arthritis?
Chris: Yeah. Rheumatoid is more of an immune response. That's the one that your immune system is attacking the joint per se. Osteoarthritis is the wear and tear that we all, at some point or another as we age, are going to develop. It's that wear and tear. It's the tissues around the knee, specifically, the cartilage starts to wear down. That's our shock absorber.
Brad: So, on the knee, the cartilage, we're looking at, right on the bottom of the femur and the top of the tibia here is where the two bones articulate or that's where they rub together. These surfaces here are nice and white and shiny when they're healthy. With arthritis, it's kind of like they're rusty and they start to develop pits and they're not shiny anymore. When the bones and the joints go together, instead of being nice and smooth, it starts to grind. It makes noises. We call that crepitus. And pain is almost always associated with it.
Chris: Yeah, and so then that continually devolves in bad cases of it. So, what do we do? That's the big million-dollar question. Are we all doomed to have knee replacement surgery? And the answer is no.
Chris: So that's the good thing. That's where you come in, Brad, where you're so adept at everything that you can do from an exercise and strengthening aspect. But you know, a lot of it comes down to, what else can we do that is maybe non-drug related? So, it's going to be weight loss. If we've got a BMI over 30, there's a seven times higher chance that you can develop knee osteoarthritis.
Brad: So like if you're 5'6" and you weigh 180 pounds, your joints are taking quite a bit more than if you were thinner.
Chris: Yes, applied physics.
Brad: But you know, weight loss is very hard, very challenging for many people. It's difficult for many reasons.
Chris: Correct. And so, what's next? Then it's strengthening that leg so that we can take care of that joint.
Brad: And actually, it's a therapist’s point of view, before we get into some of the other options, if you do have arthritis in your knee, it hurts when you walk, it feels better when you sit down, you need to check your range of motion. I'm not going to get into this in too much detail but look at your range of motion. You need to have a full extension. The knee needs to be fully straight. Compare your sore knee to the other knee, hopefully, your other knee is not so bad. If it straightens out all the way and the other one doesn't, it's very common with a painful knee. We have nice videos that show how to stretch the knee and this is one of the exercises. Simply stretch it gently like I'm doing here.
Brad: You also want to look at the range of motion and make sure it flexes or bends all the way.
Brad: And then when you get that full range of motion, you want to do exercises that keep the joint moving without weight bearing. In other words, a stationary bike. You could just put a towel on the floor and rub it back and forth. There's the Knee Glide made specifically for that, particularly on carpet or you can put it on an angle which makes quite a difference when you have a sore knee. So those are a couple of options. But if you Google Bob and Brad arthritic knee pain or arthritic knee exercises, we've got a number of videos that should come up and you can look at those and it'll go through those exercises in detail and get your knee feeling better or ranged out. And either way before surgery, you definitely want to have that. Pre-op they call that. But if you're just trying to maintain and avoid surgery, you still need to do that.
Chris: Yes. Absolutely.
Brad: Go ahead. I'm sorry, Chris.
Chris: Oh, no, no, no. I think that's important to interject all those things because, at the end of the day, it's really about joint and joint integrity and preservation. You heard me say that not everybody's going to end up with a knee replacement. We can do a lot of different things. We talked about briefly controlling the weight if we can. Otherwise, strengthening exercises, which I think is absolutely paramount and critical. But actually, how we eat and feed ourselves is actually pretty important. So there's a variety of different things and actually, be kind of cool to do a video with Jordan on this.
Brad: Oh, sure.
Chris: Osteoarthritis diet. But there are a lot of foods out there and please feel free to Google it. You can look at foods that help prevent inflammation and also nourish your cartilage. So we often used to think that cartilage couldn't regenerate itself, but that's really not true. It regenerates very slowly at a glacial pace. So it's not going to be anything quick that can really just go ahead and just "I'm going to eat so well that my cartilage goes back to its normal spongy status." It doesn't really do that, but we can do things to slow it down or kind of regain some of that integrity of it.
Brad: So, we probably don't want to get into details of a diet, but in general, are there some rules?
Chris: Yeah, it's going to be your fish, like salmon and sardines, because they're going to have the omegas in there. It's going to be your green, leafy vegetables like kale and spinach and broccoli, those types of things. Things like beets and blueberries. They all kind of work together synergistically. So you want to have a very complete diet. That helps to kind of give your body the things that it needs to protect itself to reduce inflammation. When you eat kind of an anti-inflammatory diet, it helps to prolong and nourish those joints, and all of our body not just our knees. But we're talking about the knee today. So, I think that's very important.
Brad: And if you eat that way, your joints are going to become healthier and you're probably going to lose some weight. It's a win-win situation.
Chris: It is. Yeah, it's a self-fulfilling prophecy in a lot of ways. But there are times where, let's say, you're a runner, or you tweaked it when you're a kid playing football or tennis. There are a lot of reasons why. Genetics withstanding. Male versus female, and I think that's an interesting thing too, is that most osteoarthritis in the knee is 60% female.
Brad: Oh, really? Because they work harder.
Chris: They definitely work harder and they're totally stronger. But at the end of the day, it's also a little bit of just how their bodies are designed with the hip angle. I don't think we'll get too in-depth in that because that'll put you to sleep. But at least we see that with the statistic. I mean, you're looking at 600,000 knee replacements a year, roughly. That's only 6000,000 people per year. I mean, there are a lot of people that are walking around.
Brad: That's just in the States, right?
Chris: Yes. That's a US figure. So, with that, what do we do? Well, we move on, we do the physical therapy, we try pain relievers like ibuprofen and Tylenol or Aleve those things are useful.
Brad: And those are okay, I'm assuming.
Chris: They're okay. Yep. And they definitely help, but again, they begin to run out of gas. So what do we do to try and preserve this, and calm things down? So let's say you got a wedding you need to go to and you don't want to have knee replacement surgery and you want to prolong it, or maybe we can prolong it so that we get healthy so that we don't have to have the surgery. Those are options that are on the table. There are two main things that doctors use in their toolbox and it's going to be your hyaluronic acid shots or your corticosteroid shots, the steroid shots.
Brad: Okay. Now I'm just going to say you just said that in you're pharmaceutical terms.
What would people recognize that as?
Chris: So, a lot of times, I think doctors kind of talk about the rooster shot or the rooster comb shot. One brand name is Synvisc, but there are about five or six other manufacturers out there. Some actually use the rooster comb, but other ones have found different ways to make the medication to minimize poultry allergies and things like that.
Brad: And those, I understand, actually try to regenerate the cartilage or add to it.
Chris: I think they aren't going to really regenerate it, but it's going to help to lubricate it. So if I had a can of WD-40 and I could spray it in your joint, and that's what these, specifically called viscosupplementation. So, we'll talk about the hyaluronic acid or rooster shot first. That one, it's a mixed bag of nuts. You know, all these shots are really designed for mild to modest osteoarthritis. So when it's severe, you can't do it. If you've got an infection, you can't do it. So there are limiting factors to these things. So, when you are bone on bone, these shots won't do any good. When you still got a little cartilage left, that's hanging on, I mean, hyaluronic acid shots or rooster shots can last up to six months. And it's a series depending upon the product your doctor chooses for you. There's a one, a three, and a five-shot series, so it just kind of depends on the product that's utilized. They're covered by insurance, which is good because they're about 1,200 bucks a pop.
Brad: So Medicare in the United States will cover that?
Chris: Medicare in the United States covers it. And I would imagine that over in Europe, there's probably a similar type of thing, but I'm not very well versed in that so I don't want to throw words in anybody's healthcare system.
Brad: So that really is a conversation between you and your doctor because there are all these little variables. You need to decide, is that right for you.
Chris: I think just to keep it organized, the hyaluronic acid or rooster shots, help once they find where they need to put it. They'll do a very extensive workup for you and figure out what's going on. They're going to put it into the knee joint itself.
Brad: So they use a needle.
Chris: Yep. They use a needle and they squirt it in. It's usually about five, or six milliliters, which is just about a teaspoon full of liquid. So, it's just a teeny tiny amount. So it's not much. A little bit goes a long way. So they place that, and sometimes they'll use ultrasound to show where the needle needs to go and place it. Sometimes that knee can be pretty swollen, so they might pull a little bit of fluid out to make room and put that in. That's twofold because also pulling some of that pressure off actually allows that knee to feel a lot better too.
Brad: So they pull fluid out, your bodily fluid out because it's all swollen.
Chris: Yeah, it's effusion swelling.
Brad: To give it room to put in the medicine.
Chris: Yes, so it's an important step. So it's just something so you're mentally aware and you know these steps may be coming. Not everybody has that happen. Sometimes it's not quite that inflamed, so it's not necessary. Again, your doctor is very well-versed. They are so strong in these areas.
Brad: Yeah, I agree.
Chris: It's above my pay grade. But the reality of it is it's just something that you will have to probably be prepared for, at least mentally. When they inject that in there, depending upon the product that they use, whether it's the one shot, the three, or the five. If you're coming back, it’s every week for three weeks, it's every week for five weeks or the one-time shot. So, your doctor is going to determine which one of those is most appropriate for you given your allergies and withstanding. They're going to place that in there and you have to have rest for two days after this shot. You can't just go out, "I got my shot, I'm all lubed up. I'm ready to run a marathon." It's not happening. So, it's actually very important to listen to your doctor's advice during the healing process to make sure that it sets properly, helps to bathe and nourish the existing cartilage that’s left, and help to create that good lubrication as we saw in the knee joint itself. It can last. The unique thing about the hyaluronic acid or rooster shots is the pain relief, in many cases, is more durable or longer lasting than what you get from the steroid, which is the next drug we're going to talk about.
Brad: Right. I just wanted to make mention because I had my mother in, her weight is not healthy. She's got other issues. Surgery's not an option for her. And they talked about this shot and then they talked about the steroid. And after a little discussion, my mom wanted me there because "Oh, the therapist, he'll know what to do," so it was my decision, not hers in her mind. But it was pretty easy in her case, we decided on the next option. The steroid.
Chris: Yeah. The steroid shot. It's a corticosteroid. The reason that those are, in many cases, favored over the hyaluronic acid shots is it provides more immediate pain relief early on. The hyaluronic acid shots take a little time to develop like in their wheelhouse maybe.
Brad: So you're talking about weeks?
Chris: Yeah, like about four weeks, and then it can last up to six months. So, it just kind of depends. Again, it's bathing and nourishing the joint. But for a lot of patients, and a lot of the research suggests, it's inconclusive or inconsistent relief. So, it's not for everybody and it's not for every circumstance and your doctor will recognize that very clearly and give you the options as they did like with your mom. So, the next option that we talk about is the steroid shot or the glucocorticosteroid shot, and that's the one that helps to reduce inflammation. By reducing inflammation, or swelling in there, it calms that down to hopefully allow your body's natural healing processes to take place. But we have to be careful when we're doing a steroid shot in any joint, but we're talking about the knee today because too many of them can actually degrade the tissue, the bone, the cartilage, and even the tendons. So, the example that we always see in a lot of cases, at least with the tendons, is, that we've seen a dry rubber band. So, you know how stretchy and how elastic a nice rubber band is. You can pull it and it goes back. If it were your cartilage, it kind of behaves the same way or if it's tendon, it behaves the same way. But when we use too many of these steroid shots and the magic number is four. You don't want to go more than four in a year. So, you keep three to four months in between those shots to help allow the drug to metabolize out and make sure it doesn't make it brittle.
Brad: So, it's like an old rubber band in the sun.
Chris: Old rubber band and it just pulls apart and it breaks. It may actually decrease the ability of the body to regenerate its own cartilage and it degenerates on the bone itself. So, questions your doctor will screen you for making sure there's no infection, making sure there are no allergies to certain components. It's kind of funny to be allergic. There are some people that are allergic to steroids, which is a strange irony because people get steroids to treat allergies in a lot of cases. But there are small circumstances. So again, you would be acutely aware of that because you would've experienced something quite negative. So your doctor will screen you to make sure it's appropriate and moving forward, we're going to say you are, they're going to place it again very carefully. You know, they might pull some fluid out, and then they're going to put it into your joint. A lot of times they mix it with a pain reliever called lidocaine and it helps to numb it. So, a lot of times, patients experience almost immediate relief and that's a little bit of a slippery slope because all of a sudden, "Wow, my knee feels really good, doc. I'm going to go mow the lawn." Or whatever. And again, the answer to that is no. You want to take a couple of days off to allow that shot to take place and let some healings begin. And then you can begin to strengthen, exercise, and enjoy.
Chris: So, we have to be really careful with that too. The side effects of both the hyaluronic acid shots or the rooster shots and the steroid shots are almost similar. So you want to report to your doctor if you get a little bit of irritation, or get some redness. Sometimes with the steroid shot, you can get some blanching of the skin if it's placed closer to the surface. So some little tweaky things that people notice from time to time. But generally, very safe, very effective choices to try and help to reduce that inflammation, improve pain and hopefully stave off or even maybe not have surgery. I mean, your mom responded unbelievably well.
Brad: She did. She went in, the doctor was very good, he explained it to me and to my mother so we both could understand it. She got the shot. I mean, it wasn't even scheduled. We were just there for knee pain and I thought he was going to say, "Come back next week and we'll give the injection." He did it right there. It was almost pain-free for her. I thought it was one of those things where you kind of bite the bullet while they inject, but it wasn't.
Chris: These guys and gals are so skilled. They are so good at what they do and they just understand anatomy and physiology so greatly. I mean, they're there to help heal, that's their job. I think that they utilize the tools in the shed to maximize it. Sometimes the inevitable is going to happen where the damage just is too great, and we have to have the replacement. But you know, there's a lot of people like your mom that are in that quasi-state. The other thing that we have to look at is whether we use the hyaluronic acid shot or the steroid shot, healing can begin. So if we're working on that strengthening, we can prolong or maybe even avoid that surgical result. So I think that's really critical to take home.
Brad: In her case, it was last fall, and she got the shot. Within a week, she was feeling better and she hasn't mentioned knee pain since.
Chris: Proofs in the pudding.
Brad: Yeah, I'm very happy with that. Are we going to cover something else with this?
Chris: I don't know that we were. I mean, we could talk about platelet enrichment if you want.
Brad: Oh, is that an option?
Chris: It's an option, but it's a little bit on the fringes.
Brad: So, we're talking about PRP? I just got introduced to that with my shoulder issue and I watched a continuing education course last night about it for hip issues. So, it's like, "Oh, this is new, but it's out there."
Chris: It's new. It's out there. The research is kind of all over the map. There are not a lot of consistent ways that doctors have been doing it. So, I think if they can find a more consistent way to deliver it, I think it's got promise. Because of what they do, they centrifuge it out, they oxygenate the blood, and they put the platelets back in.
Brad: So, they actually take your own blood out.
Chris: They're using your parts and that's what's nice because you're not going to be allergic to yourself.
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