A decade or so ago if you were 45 years or older and went to your family doctor with knee pain the usual first course of action was pain meds and some imaging (x-rays and or ultrasound to start).  In many cases the follow up visit may have considered advanced imaging (MRI or CT) and/or possibly a referral to an orthopaedic surgeon.

 

This clinical process made sense under the premise that knee osteoarthritis was a “wear and tear” injury.  However a decade or more of research has shown that the degree of structural changes demonstrated in the knee joint on imaging (x-ray, CT or MRI) do NOT correlate well will the level of pain or disability a person experiences.  Some patients have very minimal structural “wear and tear”  and very bad symptoms, while others have very high levels of visible “wear and tear” and minimal symptoms.

 

Finally this mounting body of literature sounding the alarm on the lack of correlation between structure and pain, has led to changing treatment guidelines.  And if you’re an orthopaedic surgeon specializing in the knee, these changes are not for the better.

 

An updated (2024) version of the often cited Australian Osteoarthritis of the knee clinical care standard is taking a strong stance to minimize unnecessary imaging and surgical procedures in the management of osteoarthritis of the knee.

 

“Imaging is not recommended for initial diagnosis of osteoarthritis of the knee as imaging does not significantly help with decisions on management.”

 

The Knee Osteoarthritis Clinical Care standard also does not recommend arthroscopic procedures (often called a scope or clean up of the meniscus) for patients with degenerative changes.  And if you’re 45 years or older, that’s pretty much everyone.  Degenerative changes are just a normal feature of biological aging.

 

Ya ya, we’ve heard this before.  But will anything actually change in our dysfunctional health care system?

 

In Australia it already has.  Since the release of the first Clinical Care standard for osteoarthritis of the knee in 2015 rates of knee arthroscopy services have plummeted by 47% within the Australian Medicare Benefits Schedule.  This most recent version release is expected to deliver another blow to the use of arthroscopic procedures for those patients with evidence of degenerative changes.

 

We have been a little slower to adapt to these changes here in Canada.  A study published in the Canadian Journal of Surgery in 2022 found that arthroscopic procedure rates for the knee were still increasing although surgeons had changed their coding for these procedures from treating osteoarthritis to treating “meniscal derangements”.

 

But we know cartilage defects and meniscal derangements in those over 40 are extremely common and don’t correlate well to patients symptoms.  So no matter how you code it, if the result is a total knee replacement a couple years later, then the arthroscopic procedure was an unnecessary additional risk to the patient and cost to our universal health care system.

 

In addition, arthroscopic surgery of the knee may actually accelerate your timeline towards a total knee replacement.  Check out the article we wrote on this topic back in 2020.

 

So what do the updated guidelines suggest?

 

Getting a Proper Diagnosis

 

A good thorough history and physical examination by a qualified health care practitioner is sufficient to diagnose the condition.  An x-ray is generally not required.  Features such as morning stiffness, pain along the joint line, joint swelling, loss of range of motion, pain with weight bearing activities, significant increases in joint clicking or grinding can all be tell tale signs of symptomatic knee osteoarthritis.

 

It is important to rule out alternative potential causes for your knee pain so your clinician may require further testing to eliminate the possibility for alternative diagnostic causes in some cases.

 

What is the best way to manage knee osteoarthritis?

 

Non-surgical treatments work well for most people with osteoarthritis, regardless of their age or severity of their symptoms.  9 out of 10 patients with symptomatic knee osteoarthritis can self manage and avoid a total knee replacement.

 

Treatment starts with education.  We have to change the way we think and communicate about knee osteoarthritis.  It is not a wear and tear injury.  Physical activity will not cause further damage to your knee joint.  Exercise is safe and can reduce pain and disability with much lower side effects that common pain medicines such as non-steroidal anti-inflammatories (NSAIDs) and paracetamol (Tylenol).

 

Weight management is important for patients who are overweight or obese.  When combined with physical activity, weight loss can significantly reduce knee pain and disability.  Every little bit of weight loss can help, so start with a very achievable goal to start.  In some cases working with a nutritionist or getting some nutrition counselling may be a key co-management strategy.

 

Physical activity and exercise is the cornerstone to effectively managing knee osteoarthritis.  There is no perfect exercise plan or routine.  Stay away from the “Guru’s” who espouse this perspective.  Many types of exercise can be effective, however some combination of strength training and aerobic/cardiovascular exercise is ideal from a wholistic health perspective.

 

Lower impact exercises like walking, cycling or swimming may be an option, but there is no “arthritis activity approved list”.  You dictate what your knee can handle.  You get to decide if the consequence and recovery of playing a sport you love causes too much subsequent pain and disability.

 

Many patients can self manage this exercise process including pacing their exercise plan and building in adequate recovery.  For many this may seem intuitive.  For others you may need some guidance.  This is where a good physiotherapist, trainer or exercise rehabilitation specialist can play a significant role: help you evaluate potential options to get started, set goals to increase your physical activity over time and help manage symptoms.  And check in regularly with your therapist on how those goals and symptom management is progressing.

 

The guidelines state that pain medicine should not replace treatment such as exercise and weight management, but can be used in addition to help manage pain.  Paracetamol (Tylenol) and NSAIDs (such as Celebrex) are recommended.  Opioid medications are not recommended as the risk of harm outweighs any potential benefits.

 

What about knee joint replacement surgery?

 

9 out of 10 people with knee osteoarthritis can self manage their condition without joint replacement surgery.

 

The new care standard recommend joint replacement surgery only be considered for those with severe symptoms who have already tried non-surgical treatments for at a minimum 12 weeks.

 

If you are a candidate for a knee replacement it’s important to note that being healthy and strong prior to surgery will help you recover better afterwards.  So a continued pursuit towards a strong exercise plan should still continue.

 

As a bit of a side note, from a cost analysis perspective, a recent study published from St. Michael’s Hospital in Toronto estimated that the direct cost per patient for a total knee replacement (including pre op, surgery and post op care) was $10,476.53.  Compared to non surgical management within their program which amounted to on average $925.43 over the 2 year study period.  You can expect this to be an increasing part of the conversation here with our public health care system coming under continued increasing economic pressures.

 

So if you go to your doctor and they are still using the term, “wear and tear” and recommending imaging, politely send them the update clinical care guidelines.

 

Find yourself an exercise and nutrition ally that can help you navigate the short term frustrations of your knee and help you see the big picture of keeping fit and healthy while managing your knee.