Non-Operative Treatment of Knee and Hip Arthritis

By Dr. Alan Puddy

August 2022

Non-Operative Treatment of Knee and Hip Arthritis

Osteoarthritis is the most common joint disorder in the United States and the leading cause of disability, resulting in a tremendous physical, mental, and economic burden.[i]  The condition is irreversible once it has begun and generally worsens over time.  Patients experience a wide range of symptoms related to the condition, including pain, inflammation, decreased range of motion, difficulty performing activities, and decreased quality of life.  Treatment of knee and hip arthritis is also multi-faceted with various surgical and non-operative options.  In this article, the non-operative choices will be covered in further detail.

 Activity Modification

Often seen as the mainstay of initial treatment for arthritis is weight loss and exercise.  Clinical studies have clearly shown that a 5-10 % loss in weight results in significant pain improvement, less disability, and better quality of life.[ii]  However, an even more significant effect is seen with the combination of diet control and exercise with regard to reduction in pain and improvement in joint function.[iii]  Regarding exercise, many factors have been studied in programs ranging from simple walking regimens to dedicated strength training with and without physical therapy.  These studies demonstrated that increasing strength, decreasing restrictions in range of motion, and improving balance resulted in significantly reduced pain.[iv]  Exercise also clearly has other health benefits to patients and, therefore, remains an important aspect in many treatment plans.

 Braces

Many patients utilize bracing and/or compression sleeves in their treatment of knee arthritis.  Research has mostly investigated the use of specific rigid braces designed to transfer the force from an area of the knee with significant cartilage wear to an area where less severe arthritis is present.  Evidence for these braces was determined to be inconclusive in a large review of clinical data and, therefore, these devices are not recommended by the American Academy of Orthopedic Surgeons (AAOS).[v]

 Medications and Supplements

Perhaps the most common and widespread non-operative treatment utilized by patients is the use of oral and topical medications.  Research has also focused on a search for dietary supplements for the treatment and potential reversal of arthritic changes in the hip and knee.

 Acetaminophen

Acetaminophen has been considered a first line treatment for arthritis for decades, but its role has been a subject of debate more recently.  Acetaminophen reduces pain by decreasing the production of compounds called prostaglandins in the pain pathway and altering serotonin levels in the central nervous system, but the exact mechanism of its action remains poorly understood.  In direct comparison with non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen has been shown to be less effective regarding pain control and improvement in disability.[vi]  As a result, it is no longer recommended for knee and hip arthritis by the AAOS or the Osteoarthritis Research Society International.

 NSAIDs

In contrast to acetaminophen, NSAIDs have been endorsed as first line arthritis treatment by the AAOS, the American Academy of Family Physicians, and the American College of Rheumatology.5,[vii]  This class of medications are available both over the counter and by prescription and include medications such as ibuprofen, naproxen, meloxicam, celecoxib, and diclofenac.  All of these medications function by inhibiting enzymes called cyclooxygenases (COX), but are generally classified into two groups.  Non-selective NSAIDs are those that inhibit both COX-1 and COX-2 enzymes, while selective NSAIDs are more effective against COX-2 enzymes.[viii] 

While both groups of NSAIDs have relatively low risk of side effects, several notable adverse events can occur with these medications.  Non-selective NSAIDs, such as ibuprofen and naproxen, carry the risk of causing both gastrointestinal and cardiovascular events, including stomach ulcers, gastrointestinal bleeding, heart attacks, and strokes.  Selective NSAIDs, such as celecoxib, have improved safety profiles regarding gastrointestinal events, but demonstrate an increased risk of cardiovascular events especially when taken continuously for more than five years.  As a result of these potential side effects, recommendations include intermittent use of the lowest effective dose when possible.

Another strategy to avoid the potential complications of oral NSAIDs is the use of a topical NSAID medication.  Diclofenac gel, for example, can be applied to the area of pain and the medication is absorbed through the skin.  Since this avoids the exposure of the gastrointestinal tract and the amount of the medication circulating throughout the body is significantly less, the risk profile of this medication is improved.   Diclofenac has been shown in clinical studies to provide improvement in pain and function in patients with mild to moderate knee arthritis, but is less effective in patients with more severe disease.[ix]

 Opioids

Opioid medications have a direct effect on the central nervous system to improve pain.  While they generally provide excellent pain control in an acute setting such as after surgery, their use in chronic pain is limited.  The adverse events associated with chronic opioid use include addiction, nausea, vomiting, urinary retention, and respiratory depression.  Opioids have also been shown to provide inferior pain control over long periods of time as compared to NSAIDs.  Additionally, chronic use of opioid medications leads to tolerance and a need to increase the dose in order to obtain the same level of pain management.  For patients taking opioids chronically and requiring surgery, clinical studies have shown higher pain post-operatively, lower functional improvement from surgery, and a higher overall risk profile.[x]  As a result, the chronic use of opioids is largely reserved for patients that are not eligible for other interventions and are deemed to be too high risk for surgery.

 Chondroitin Sulfate and Glucosamine

Chondroitin sulfate and glucosamine are compounds that serve as building blocks of cartilage.  Natural forms of the compounds are available as dietary supplements and are used by many patients for treatment of their knee and hip arthritis.  They have been shown to be very safe and the use of these supplements is logical in theory, but their clinical effectiveness has been called into question.  Multiple research studies have compared chondroitin sulfate and glucosamine use with either placebo or other oral treatment regimens with inconclusive results.[xi]  Some patients have reported improvements in symptoms and function, but the clinical results are not compelling enough for the AAOS to recommend their routine use.  Given the excellent safety profile, however, these medications may be continued by patients if they are providing clinical benefit.

 Fish Oil and Cherry Extract

Fish oil contains two important omega-3 polyunsaturated fatty acids that have been shown to have anti-inflammatory activity.  Fish oil supplements have been studied most thoroughly in rheumatoid arthritis and showed clinical benefit for patients, so additional studies in osteoarthritis have also been completed.  While no large studies have been performed to date, a recent study showed that a 16-week supplementation with fish oil resulted in significant reduction in osteoarthritis related pain and improvement in patient’s well-being.[xii]

Tart cherry juice contains relatively high levels of polyphenols, which are another class of dietary compounds with anti-inflammatory properties.  Fewer studies have been performed on this supplement.  While a study in 2013 demonstrated a reduction in a blood inflammatory marker with tart cherry juice supplementation, no clear demonstration of arthritis improvement was found.[xiii] 

While fish oil, tart cherry juice, and a few other supplements have shown some anti-inflammatory properties, the use of these compounds should be approached with some level of caution.  The FDA does not play a role in approving dietary supplements and, therefore, there is the potential for adverse reactions to them related to factors such as the presence of impurities, variations in dosing between batches, and lack of robust monitoring for adverse events. 

 Joint Injections

As knee and hip arthritis becomes more symptomatic for patients and treatment options such as activity modification and oral medications are less effective, another option in the non-operative treatment is a joint injection.  Multiple types of injections are available and widely utilized, including steroids, viscosupplementation, platelet-rich plasma injections, and stem cell injections. 

 Steroids

Corticosteroid injections into the knee and hip help control the inflammation and pain caused by arthritis. Several medications in this class are available as treatment options and have been studied in many clinical trials.  The results have consistently demonstrated symptomatic relief, although the duration of that relief varies widely across the patient population.  Most patients experience at least several weeks of pain relief after injection, although very little data suggests any ongoing effectiveness beyond 6 months.[xiv]  Additionally, there is significant concern that these medications cause further cartilage damage especially after multiple injections.  Therefore, it is generally recommended to avoid frequent joint injections and to consider them only after symptoms have returned.

 Viscosupplementation

Viscosupplementation involves the injection of hyaluronic acid into the joint.  Hyaluronic acid is a natural component in joint fluid and these injections have a thick, gel-like consistency.  After injection, hyaluronic acid is believed to lubricate the joint surfaces and help absorb shock during weight-bearing.  Several different hyaluronic acid products are on the market with dosing that varies from a single injection to a series of up to five injections.  In most patients, the injections have a good safety profile, but they can result in a painful reaction in a small subset of patients.  The clinical effectiveness of these injections also varies.  Some patients describe significant relief lasting multiple months, while others report little to no improvement.  Clinical studies of these medications are also inconclusive when compared to steroid injections or oral medications.[xv]

Platelet-Rich Plasma (PRP)

PRP is made from patient’s blood that is spun in a centrifuge to separate the blood into several different components.  It contains a higher concentration of platelets, anti-inflammatory compounds, and growth factors after this processing.  PRP is currently FDA approved for procedures with bone grafts, but PRP use as an arthritis treatment continues to increase.  Injection of PRP for arthritis, however, is considered off-label use of PRP so many medical insurance plans will not cover the cost of this treatment.  Despite this, there is growing evidence that these injections improve pain, function, and quality of life.  Research has even shown that these improvements have continued for six months to a year in some patients, especially those in less severe categories of arthritis at the time of the injections.[xvi]

 Stem Cells

Injections of stem cells are one other type of joint injection currently being heavily investigated and used in some patients.  Stem cell injections are considered investigational at this point and not covered by insurance.  Stem cells can come from a variety of sources, including the patient’s own bone marrow or fatty tissue, but can also be harvested from placental tissue.  The use of these cells continues to be a source of debate, but they show some promise regarding their ability to repair cartilage damage and reduce inflammation.[xvii],[xviii]  The effectiveness of treatment, method of processing, frequency of use, and dose of stem cells are all still under investigation.  While some studies have demonstrated positive results in some patients, no large clinical trials have been completed to date. 

 Acupuncture

Acupuncture is a treatment modality that is used widely around the world and has been studied thoroughly in the treatment of pain.  Multiple clinical studies have also been undertaken specifically for the treatment of arthritis and several of them have demonstrated a link between acupuncture treatment and reduction of arthritic pain.  A recent randomized controlled trial specifically compared electroacupuncture, manual acupuncture, and sham acupuncture in an eight-week trial.  The comparison demonstrated improved pain and function of the electroacupuncture group, but only about 60% of patients experienced improvement.[xix]  

 Chiropractic Care/Manipulative Therapy

Chiropractic care for osteoarthritis is another possible treatment with some evidence in the medical literature.  The manipulative therapy that chiropractors can employ involve joint mobilization and manipulation techniques for those joints with limitations in range of motion.  In addition, they can provide education regarding the condition and other rehabilitation programs that the patient may utilize to further improve their results.  In a recent study comparing manual and manipulative therapy (MMT) alone, MMT with a rehabilitation program, and a rehabilitation program alone, both treatment categories utilizing MMT showed improvements in function scores for patients with arthritis.[xx]

  Conclusions

As described above, many non-operative treatments are available for those patients dealing with the discomfort and limitations of osteoarthritis.  By the time many patients are seen by Orthopedic providers for their arthritis, many of these treatments have already been implemented.  An important component of treatment, especially when multiple treatment modalities are involved, is the continued oversight by health care professionals to ensure that treatment plans are optimized and patient risk of adverse events are limited.  Arthritis is a very common condition and results in significant pain and limitations that may be well-controlled using the treatments described here.  Unfortunately, in other cases, arthritis may progress to a point where non-operative treatments are no longer allowing acceptable improvement in pain or function.  In those cases, further discussion with a qualified Orthopedic specialist is certainly warranted.

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[ii] Chu IJH, Lim AYT, Ng CLW: Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: A systematic review and meta-analysis. Obes Rev 2018;19:1597-1607.

[iii] Messier SP, Mihalko SL, Legault C, et al: Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. J Am Med Assoc 2013;310:1263-1273.

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[vi] Da Costa BR, Reichenbach S, Keller N, et al: Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: A network meta-analysis. Lancet 2017;390(10090):e21-e33

[vii] Bannuru RR, Osani MC, Vaysbrot EE, et al: OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil 2019;27(11):
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[xi] Clegg D, Reda D, Harris C, et al: Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med 2006;354(8):795-808.

[xii] Kuszewski, J, et al: Fish oil supplementation reduces osteoarthritis-specific pain in older adults with

overweight/obesity.  Rheumatol Adv Pract. 2020 Jul 23;4(2):rkaa036.

[xiii] Schumacher, HR, et al.  Randomized double-blind crossover study of the efficacy of a tart cherry juice blend in treatment of osteoarthritis (OA) of the knee.  Osteoarthrtis and Cartillage. 2013; 21(8): 1035-1041.

[xiv] Jüni P, Hari R, Aws R, et al: Intra-articular corticosteroid for knee osteoarthritis: Summary of findings for the main comparison. Cochrane Database Syst Rev 2015;(10):2-3.

[xv] Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA: Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006;(2):CD005321.

[xvi] Shen L, Yuan T, Chen S, Xie X, Zhang C: The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: Systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2017;12:16.

[xvii] Themistocleous GS, Chloros GD, Kyrantzoulis IM, et al: Effectiveness of a single intra-articular bone marrow aspirate concentrate (BMAC) injection in patients with grade 3 and 4 knee osteoarthritis. Heliyon 2018;4(10):e00871

[xviii] Carr JB II, Rodeo SA: The role of biologic agents in the management of common shoulder pathologies: Current state and future directions. J Shoulder Elbow Surg 2019;28(11):2041-2052.

[xix] Tu, JF, et al. Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized

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[xx] Dwyer, L, et al. Manual and manipulative therapy in addition to rehabilitation for osteoarthritis of the knee: assessor-blind randomized pilot trial. J Manipulative Physiol Ther. 2015; 38(1): 1-21.e2.