Arthritis is a debilitating condition that affects people of all ages. In many people, it begins as a niggling pain in the knees – often dismissed as over-exertion or just the effect of aging. However, if the pain persists for a few weeks, it is a sign of possible joint damage. It is very important to diagnose the cause of knee pain and begin treatment early to prevent further joint damage.
Prevalence of Arthritis-Related Knee Pain in Singapore
Arthritis is a common health problem. Arthritis develops through the interaction of genetic, metabolic, and microenvironment factors. However, with 68% of those aged 65 in knee pain Singapore being affected by the disease, it is more than a disorder related to old age. This statistic is provided by the Tan Tock Seng Hospital (TTSH) Chronic Disease Management Unit (CDMU), but it is not clear what type of arthritis this statistic accounts for. Osteoarthritis, gout, and rheumatoid arthritis are the three most common arthritis conditions in Singapore. Osteoarthritis affects 9.9% of the population, with gout affecting 4.3% and rheumatoid arthritis affecting roughly 1%. The population of people living with arthritis in Singapore is rapidly increasing due to both an ageing population and lifestyle changes over the years. These lifestyle changes include increased usage of mobile phones, watching television, and using a computer. Over the past 20 years, the prevalence of osteoarthritis has increased over all age groups. The highest increase has been in those aged 45-64 years from 18.6% to 49.4%. Gout prevalence has also increased over the same age group, doubling in those 18-44 years of age and tripling in those aged 45-64 years.
Causes and Risk Factors
Osteoarthritis (OA) is the most common form of knee arthritis and is experienced by more than 10% of individuals aged over 55 years. It is a complex condition that can be caused by many factors. In the past, OA was believed to be a consequence of wear and tear on the joints, resulting in thinning of the cartilage and overgrowth of new bone in the form of spurs (osteo=bone, arthr=joint, itis=inflammation). However, it is now known that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and underlying bone. Changes that occur in OA can be divided into those that are part of the normal aging process of the joint and those that are accelerative and pathological. An understanding of the causes of OA changes is helpful in developing strategies to prevent and treat the condition. (i) Aging process changes These changes are inevitable and occur in everyone to varying degrees. They are thickening of the bone beneath the cartilage, formation of channels in the bone just below the cartilage, and alteration of the cartilage matrix.
Primary Causes of Arthritis-Related Knee Pain
Arthritis is a general term that refers to over 100 different medical conditions. An important common symptom of the many forms of arthritis is the increased risk of developing knee pain. The knee joint is the biggest and one of the most complicated joints in the human body. The knee joint is where the three bones that make up the knee – the femur, tibia, and fibula – meet. The patella, a bone that protects the front of the knee, is located over the point where the three bones meet. Since the knee bears an important part of the body’s weight while performing a multitude of movements, it is vulnerable to many different types of arthritic knee pain. Arthritis-related knee pain can be placed in two types: pain resulting from a direct injury to the joint, and pain resulting from the gradual deterioration of the joint cartilage.
Secondary Causes of Arthritis-Related Knee Pain
Secondary causes of arthritis-related knee pain include performing activities that lead to repeated stress on the knee, such as kneeling, heavy lifting, climbing stairs, or playing stop-and-go sports. Suffering a severe knee injury can damage the joint and lead to the development of arthritis in the injured joint. Some people may have an inborn abnormality of the leg that results in a misaligned joint. People with this condition are more likely to develop osteoarthritis in a joint because the misaligned joint can cause excessive wear on the joint surface. Finally, people who have had meniscal tears or other injuries to the cartilage in their knees are more likely to develop arthritis in the injured knee. This can occur many years after the original damage to the knee. In general, people with arthritis of the knee that is related to a specific activity or injury are good candidates for treatment of that arthritis.
Risk Factors for Developing Arthritis-Related Knee Pain
A risk factor is something that increases your chance of getting a disease. Some of these risk factors for knee osteoarthritis you can do nothing about, such as age and sex, which is why it is important to make the lifestyle changes that are possible to prevent knee osteoarthritis if you have other risk factors that can be changed. The leading risk factor for knee osteoarthritis is overweight or obesity, which increases the risk of knee osteoarthritis and the rate of its progression. It is estimated that losing the weight that is putting extra stress on your knee can reduce the chance of developing knee osteoarthritis or needing knee replacement later. Another risk factor for knee osteoarthritis is previous injury to the knee joint. This can lead to degeneration of the cartilage causing knee osteoarthritis. There are also certain occupations that can increase the risk of knee osteoarthritis if they involve a lot of squatting and heavy lifting. High level sports participation can also increase the risk of knee osteoarthritis due to repeated trauma or injury to the knee joint. It is important to try and limit the amount of trauma to your knee throughout your life as much as possible to decrease the chance of developing knee osteoarthritis in the future.
Diagnosis and Treatment Options
Treatment: As the first article in a series called “Cochrane Reviews”, it is no surprise that the authors focus on providing evidence for treatment options of knee OA. They use protocols of 19 reviews, representing over 11,000 patients, but do not provide overwhelming evidence of a superior treatment among any of the correlations. We recommend this article because it provides a range of treatment options, from advice and education to arthroplasty, each of which can be employed in different clinical settings. All decisions are based on careful consideration of risks and benefits as it is truly patient preference that drives management of knee OA.
Diagnosis: The lack of specific diagnosis in early stages of disease often causes frustration among patients with knee pain. Clinical diagnosis of knee OA is based on history of knee pain, physical findings, and occasionally use of plain radiograph. Most diagnostic studies have focused on lateral compartment OA, the tibiofemoral compartment most often affected by the disease. In general, radiographic diagnosis of knee OA is based on presence of osteophytes, joint space narrowing, and increased combination of the two features. Magnetic resonance imaging and arthroscopy are more sensitive methods for cartilage damage, though the amount of pathology is not always in proportion to extent of symptoms. There is no consensus on uni or bilaterality of symptoms, thus it is difficult to compare knees and gauge rate of progression. Unilateral disease often seems to progress more rapidly. A valid definition of progression in disease state is also lacking.
The authors focus on diagnosis, treatment, and rehabilitation of knee OA, but the amount of information and breadth of literature cited in this article does not do justice to any one of these aspects.
Common Diagnostic Methods for Arthritis-Related Knee Pain
There are some important and commonly used clinical diagnostic methods that can be used to diagnose arthritis knee pain and the type of arthritis. Joint aspiration involves using a needle to take a sample of fluid from the affected joint. This is usually carried out under local anaesthetic. The fluid can then be checked for inflammation or gout crystal deposits. X-rays only give a partial picture of what is going on with the joint, but are a useful starting point. They can help in making a diagnosis and in some cases they may be used to monitor the progression of the disease. Blood tests are commonly used to help with diagnosis. There is no one blood test for arthritis, but as well as testing for other forms of arthritis, a blood test can rule out any other conditions that may be causing symptoms. An arthroscopy is a minor surgical procedure using a type of keyhole surgery where a thin tube-like instrument is used to look inside the joint. This is usually used only to confirm a diagnosis if the knee pain doctor is unsure, as once arthritis is confirmed there are not usually many surgical options. The features that the doctor needs to see to confirm a diagnosis of arthritis are damage to the cartilage or less space between the bones in the joint.
Surgical Treatment Options
The decision to consider surgery While each of the surgical options described below has specific criteria, a few generalizations can be made. The decision to consider surgery is based upon the level of pain and limitation of activities from arthritis, and the degree to which that pain and limitation of function are affecting the patient’s quality of life. Effective surgical treatment for arthritis should provide pain relief, improved function and/or improved alignment of the involved limb, and should accomplish these treatment goals with low risk and minimal adverse effect on the patient’s overall health. Realistic patient expectations are an important part of the equation and often it is wise to get more than one opinion. Remember that the goal is not so much to have a specific procedure, as it is to find the best treatment for your problem. Often that may mean a specifically coordinated combination of more than one of these procedures. In Singapore, the goodness of the public healthcare system is such that knee replacement surgery is often financially as well as medically viable for those who might not be candidates for the procedure based upon insurance coverage in other countries. Early consideration of joint replacement may be indicated in patients with advanced arthritis who have failed non-operative treatment, especially in cases of specific deformity or of arthritis isolated to one compartment of the knee. Other surgical options for some specific cases might actually be done in conjunction with joint replacement, and the decision to do a specific procedure should always be made in consideration of the overall needs of the patient.
Rehabilitation and Physical Therapy
In addition to this, there are many aerobic-type exercises, which still need to be measured for their effect in knee OA, and some patients may go on to have body weight reduction surgery to further complement their exercise plan.
A patient will now have a choice of many forms of physiotherapy and supervised exercise classes in an attempt to improve their knee pain. The more traditional forms of exercise do still have a place, but it is believed that the most beneficial type of exercise is strength training for the quadriceps. This should be undertaken to a point where the muscle is fatigued and is done on alternate days. This is an improvement from the previous instruction of rest and non-weight-bearing exercises for knee OA patients.
From this point, it can be seen that exercise and weight loss are beneficial for preventing the onset and symptoms of knee osteoarthritis. Although the benefit has been recognized, it is not yet known to what level and intensity the exercise should be, and a definitive exercise regimen is still to be determined.
Now, there is substantial evidence to suggest that exercises and treatments to improve the power and stamina of the quadriceps can improve symptoms of knee OA. It is believed that an 11% increase in quadriceps strength results in a 50% decrease in the rate of symptomatic knee OA. It is also said that for every one pound of body weight lost, there is a four-pound reduction in load exerted on the knee for each step taken.
Once a patient has had a knee operation, it is not uncommon for them to receive no guidance or instruction on what form of exercise or physical activity is safe and beneficial. Traditionally, it was thought that once the knee joint had sustained damage, it was inoperable and the only effective treatment for symptoms of pain and discomfort was rest and medication. This was to the detriment of the knee, as prolonged rest results in muscle wastage and further worsening of the symptoms.
Lifestyle Management and Prevention
Structured exercise and unsupervised lifestyle physical activity are both effective for improving physical function and decreasing pain in people with knee arthritis. Structured exercise is best provided through physical therapy programs or fitness professionals who can instruct patients on how to safely and effectively exercise in the community. If your arthritis is more severe, it may be beneficial to provide you with instruction for exercises in water or specialized land-based exercise. Supervised programs and those offered in the community have been shown to have better long-term adherence, so it is important to have a plan to transition from formal therapy to a community-based exercise program.
Lifestyle modification involves integrating physical activity throughout the day, e.g. walking, gardening, and taking the stairs, with the goal of increasing overall activity levels. This is effective for the person who is currently inactive and feels that structured exercise is not a realistic option. Others who are able to perform structured exercise would also benefit from increasing general physical activity.
Motivating change from a sedentary to a more active lifestyle begins with setting realistic goals to adopt healthy living strategies. A successful plan to manage knee arthritis should include ways to control pain, improve function, and limit further disability. In any case, people with knee arthritis should be more physically active to gain the associated benefits. These goals can be achieved through either lifestyle modification or structured exercise.
Healthy Habits to Manage Arthritis-Related Knee Pain
Some of the most effective ways to manage arthritis-related knee pain often coincide with protecting your knees. Simple alterations to your daily routine, like alternating between sitting and standing, using a knee brace, or losing as little as 11 pounds can make a significant difference. If you have a rarely used room in your home, consider turning it into a joint-friendly space by laying down some yoga mats for floor sitting or putting up a stationary bike or elliptical tool. You may not notice relief right away but making a habit out of these activities can have lasting effects. Use adaptive tools, such as a long-handed “reacher,” to make an extension of your arm for grabbing items. These devices can be found at medical supply stores or through online vendors and help eliminate unnecessary stress on your knees and back. Ask for help. Always remember that it is not a sign of personal weakness to ask for help with chores or errands. Whether you hire someone or ask a friend, family member, or a neighbor, learning to accept help can relieve stress and make you feel more optimistic about the future.
Exercise and Physical Activity Recommendations
Finally, although it may seem counter-intuitive, sufficient exercise or physical activity is essential for individuals suffering from knee pain due to arthritis. Exercise can return the functionality and strength of the joint, increase the range of motion, decrease pain, and importantly it will postpone or even prevent the need for surgical intervention. Exercise need not be overly strenuous or heroic, and there is no evidence that more painful days are apparent in people who adopt a more vigorous exercise regime. Low-impact exercise is particularly suitable for those people suffering from arthritis, since minimal stress is placed on the joints. Activities such as swimming or bicycling will have very beneficial effects on arthritic knees, as it will help increase muscle strength and support the joint, and aerobic exercises will bring about general health benefits and weight control. It is often useful to seek out a physiotherapist when beginning an exercise program, since they can provide advice on appropriate activities and exercises, and they can recommend the use of supportive devices such as braces or insoles. Overall, the adoption of regular physical activity is an essential part of any strategy to manage knee pain.
Tips for Preventing Arthritis-Related Knee Pain
- Eat a healthy diet or take a multi-vitamin. If you have a food allergy or sensitivity, it can trigger an inflammatory response in your body that will worsen your arthritis. Studies have shown that getting the right amount of key nutrients is an essential component in managing arthritis as well as general health. Vitamin K intake (found in broccoli, Brussels sprouts) and high-quality fish oil are the two most notable at this time.
- Maintain your oral hygiene. Although this may sound far-fetched, one of the bacteria implicated in gum disease has been found in abundance in the knee joints of patients with osteoarthritis. Treating gum disease may not only save your teeth but could reduce complications with osteoarthritis and joint pain in the future.
- Correct bad posture. It will then allow for better movement and ultimately reduce the strain on your knee joint.
- Pay attention to pain, swelling, or stiffness in one or both knees. Identifying and dealing with knee problems early on can reduce the risk of long-term damage.
- Use mobility aids. Studies have found that a mix of activity and rest is better for the joints than complete rest, so by using a walking aid during flare-ups, it can keep you moving yet reduce the amount of weight transmitted through the knee joint.
