Know Your Knees with Dr. DiNubile
Content provided by Synvisc-One
Dr. DiNubile is a renowned orthopaedic surgeon, sports medicine specialist and author of Framework: Your 7-Step Program for Healthy Muscles, Bones and Joints.
Featured Questions and Answers
Q: I recently went to see an orthopaedic surgeon for knee pain. I brought an MRI from my family doctor to the visit, but the orthopaedic surgeon said that I also needed to get X-rays. Are they really necessary? I thought an MRI showed everything.
A: MRI technology is amazing because it provides information about the knee and other joints that we once couldn't see without surgery. However, they don't always show the whole picture. Regular X-rays provide very useful information and actually complement what you see on an MRI. In fact, the degree of arthritis is better determined on X-rays than on MRI scans. Your doctor is right in wanting X-rays. He or she may also ask for certain special views depending on what is found in a physical exam. X-rays of the knee are very useful and I rarely ever make a final decision about treatment without seeing them.
Q: I've heard a lot about stretching and range of motion exercises. What's the difference?
A: Stretching primarily helps the muscles while range of motion (ROM) exercises target the joints. They are both extremely important for those with knee arthritis.
Stretching is perhaps the most neglected part of our workouts. Most of us need to stretch more, especially as we age. It's best to stretch after a good warm up, and especially after your workout is concluded.
The purpose of warming up is to get blood flowing to your muscles and to raise your body temperature. A warmed-up muscle is much more likely to behave elastically when stretched and less likely to be injured or strained.
Your muscles and tendons are much like taffy. When taffy is cold it is quite brittle and can be broken into many pieces. Once warmed, it's gooey and elastic. A warm up can be simply one or two minutes of calisthenics like jumping jacks, running in place or a brief ride on a stationary bike. Lower impact activities, like bike riding, are better if you have knee arthritis.
Joint ROM exercises are especially important for those with knee osteoarthritis. They help keep mobility in the joint and prevent stiffness and motion loss that is so common with arthritis. To improve or maintain joint mobility, gently and slowly flex (bend) the joint as much as possible and hold 10–20 seconds, then extend (straighten) the joint and hold for another 10–20 seconds. Stretching and ROM exercises should be static, which means no bouncy movements.
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Overall, exercise is wonderful for arthritic joints, but not all exercise is created equal. For example, in terms of cardiovascular or aerobic exercise, if you have arthritis of the hip, knee or ankle, you should avoid higher impact activities like running and jumping. Walking is good, but some individuals with more advanced arthritis have difficulty even with that. So for them I recommend water aerobics or swimming, or even using a stationary bike or elliptical machine. Strength training is also important for arthritis, but one must be careful not to overload the joint. Check with your doctor or physical therapist about safe and effective exercise routines that are ideal for arthritis sufferers.
Absolutely. If you have early-stage osteoarthritis, exercise is important in terms of maintaining joint health and even preventing progression. If you have late-stage OA, it's still a good idea. It will improve your function and even reduce pain levels if you stick with it. Even if you need knee replacement surgery, you're going to do better if you're in better shape. You're going to come out of the surgery and recover quicker, with a better overall result.
Stairs can be a major challenge for anyone with osteoarthritis (OA) of the knee. This is because your knee has to work harder when ascending and descending stairs, putting more pressure on the already worn joint surfaces. Also, individuals with knee OA tend to have weaker supporting leg muscles which means that there is less power to negotiate stairs. Your leg muscles also act as important shock absorbers, so weaker muscles mean less protection for your vulnerable knees.
To improve your situation I would recommend daily strengthening exercises for your thigh muscles. A short course of physical therapy can be helpful in developing a program that is right for you. If you are overweight, losing even a few pounds lessens the load on your knees, especially on stairs. Also, trying not to carry heavy loads up and down all at once. Lean on the rail a little to cheat, until you get that leg strength improved.
As an orthopaedic surgeon, I'm often asked if running causes arthritis. Pounding the pavement, mile after mile, year after year — you'd think it would cause wear on your hips and knees, just the way tires on your car wear out as the miles accumulate.
The truth is that running does not cause arthritis in healthy knees. Runners are usually very glad to hear that statement until they hear my next one: If you have arthritis, running will make it worse.
Running is a high-impact activity generating forces 5-7 times body weight on your knees and hips. If you already have osteoarthritis (OA), it will accelerate the wear, damaging your joints further. If you have OA and are overweight pounding the pavement, you are even more likely to worsen the wear process.
If you have OA of the knee, I recommend gentler exercises like swimming, walking, leisurely bike rides or use of an elliptical machine if you belong to a gym. And always remember to warm up and stretch the muscles around your knee before and after exercising.
Night pain is a very common complaint in individuals with knee osteoarthritis or inflammation. There are several theories as to why pain is amplified during the night, but no one knows the exact reason for this phenomenon.
Restful sleep is very important in maintaining overall health, so anything that routinely interferes with sleep is not good for your health. Try to determine what you may be doing earlier in the day (or even the day before) that may be provoking your knee. Sometimes this takes a little trial and error or detective work. You can then modify your activities accordingly.
Your physician may also suggest remedies that can improve your situation. Some patients benefit from heat or ice in the evening, or even a little physical therapy. Others do well with an evening medication such as acetaminophen or an NSAID like ibuprofen, but I try to avoid prescribing narcotics or sleeping pills. I have had success in alleviating night pain, stiffness and other symptoms of knee osteoarthritis with the use of viscosupplement injections like Synvisc-One.
Your primary care doctor can be very helpful in managing your knee osteoarthritis (OA) especially in the earlier stages. However, specialists, like orthopaedic surgeons and rheumatologists, will usually offer a more comprehensive approach in managing your knee OA, including the ability to review and discuss many of the newer therapies such as Synvisc-One. Some orthopaedic surgeons' entire practice is devoted to knee problems, and they might even offer more suggestions for you.
I've had knee pain off and on for a few years. At my last appointment my doctor said it was osteoarthritis and I should try to lose 10 or 15 pounds. I know I should lose weight for other reasons, but is it really going to help my knee pain?
Being overweight can indeed create problems for your knees. If you are overweight, you are certainly more likely to develop knee osteoarthritis. Also, if you have some knee OA, being overweight can make the arthritis worsen and progress more rapidly. Even losing 10 pounds has been shown to make a difference in slowing down or even halting the progression of knee OA. By keeping your weight in a more ideal range, you will feel better, function better and hopefully the arthritis can be kept in check.
Carrying extra weight is problematic for your knees. This is because for each extra pound you carry, your knees feel 4 or 5 pounds. So, if you're 10 pounds overweight, your knees think that you are carrying 40 to 50 extra pounds! If you're running or jumping, the forces across your joints are even higher. Small amounts of weight are amplified across your joints and that‘s why it can be damaging to the joints. This is why a small amount of weight loss can go a long way in keeping your knees healthy.
I'm a 45-year-old ex-jock who badly injured my knee playing high school football. It's been scoped several times for cartilage tears and "cleanouts," but my X-rays now show moderate osteoarthritis (OA). I've been avoiding activities and sports and have gained considerable weight. I've tried cortisone shots, but they say I'm too young for a knee replacement. What else can I do? What are my other options?
Like many active individuals in your age group, you're in that middle ground in terms of treatment options for your arthritic knee. Because you've already been through several surgeries, more arthroscopic surgery is not the answer unless something very specific occurs, like new torn cartilage. There comes a point when minor repeat procedures really don't offer much. On the other hand, you are young for knee replacement surgery and hopefully your OA is not yet at that point.
Fortunately, there are some treatment options for you. It's often a combination of elements that can help keep you active and comfortable, plus avoid knee replacement down the line. Keeping your weight down is essential. Every extra pound you carry puts significant weight on your joint. Your knee feels approximately five pounds for every extra pound that you carry during certain activities. Strengthening your leg muscles is also very important, especially your quadriceps muscle on the front of your thigh.
Occasional steroid injections could be helpful, especially around times of significant flare-ups. But they are short-term solutions for reducing inflammation and generally last for only a few weeks. Also, too many steroid injections may be damaging to the articular cartilage or joint cushion in the knee.
"Flare-ups" are extremely common for individuals with osteoarthritis (OA) of the knee. When you have OA, your knee can be very temperamental. Inflammation of the joint can occur, something we call synovitis. Sometimes the reason for the flare-up is obvious, like being overactive, taking a long walk, dancing, or playing some tennis. Other times it seems to happen for no obvious or rational reason.
If you have a flare you should contact your doctor, who can usually manage your knee flare easily, and with some simple measures. He or she will probably recommend rest, and applying ice to your knee. Also, medications like Tylenol® can help the pain, and NSAIDs (over-the-counter or prescription) can both relieve pain and reduce inflammation. Occasionally, a cortisone shot is needed to settle things down.
If you are having flares often, then you should talk to your doctor about other options that are better for long term management of your knee OA. Viscosupplements like Synvisc-One can give a more lasting relief of arthritis symptoms than cortisone. It is a very simple and quick procedure done in the office, with minimal or no discomfort, and it can provide a more lasting relief from your OA symptoms.
Tylenol is a registered trademark of McNeil Consumer & Specialty Pharmaceuticals, a Division of McNeil-PPC, Inc.
Genzyme Corporation does not endorse Dr. DiNubile, or his book, FrameWork.
Dr. DiNubile is a paid advisor for Genzyme.
Important Safety Information
Synvisc-One® (hylan G-F 20) is used to relieve knee pain due to osteoarthritis (OA). It is for patients who do not get enough relief from simple painkillers such as acetaminophen, or from exercise and physical therapy. Synvisc-One is generally well tolerated. However, it may not work for everyone. The side effects most commonly seen in a medical study were knee pain, stiffness, and swelling or fluid buildup in or around the knee. Side effects were generally mild to moderate and did not last long. Other side effects, such as rash, may also occur. Before trying Synvisc-One, tell your doctor if you are allergic to products from birds—such as feathers, eggs or poultry—or if your leg is swollen or infected. Talk to your doctor before resuming strenuous weight-bearing activities after treatment. Synvisc-One has not been tested in children, pregnant women or women who are nursing. You should tell your doctor if you think you are pregnant or if you are nursing a child.