If you have knee pain and you are above age 40, the following information can help you determine your next steps.

Osteoarthritis is the most common form of arthritis. It describes a process where the cartilage in the joints is wearing away and causing the bones to be closer, otherwise known as narrowing of the joint spaces. The joint spaces are maintained not only by the cartilage, which is softer than bone, but also by the synovial fluid in the joint.  The synovial fluid is a thick fluid that helps with smooth movement of the joint and serves as a shock absorber for the joint. As we age, we have less lubrication in the joint, again causing a narrowing of the joint space.

The main complaint of persons with osteoarthritis is pain with walking, stair climbing and after prolonged sitting. Many individuals also report hearing a clicking sound and at advance stages there is a report of decreased ability to bend or straighten out the knees.  If you are an athlete involved in jumping sports such as basketball, you may develop osteoarthritis of the knee as early as mid- to late 20s.

Osteoarthritis is diagnosed primarily by a doctor who examines patients in order to look for signs of osteoarthritis, such as crepitation (a grinding sound or feel when moving the knee joint). Another sign may be swelling and a feeling of effusion (increased inflammatory fluid collection) in the knee. Radiology studies such as X-rays can determine the presence of joint line narrowing, as well as osteophytes, abnormal bony overgrowth due to the reaction of the wearing away of cartilage and decrease in synovial fluid.

Evaluation of the feet can help to determine a cause of knee pain. Flat feet and hyperpronation of the foot (turning in of the foot / ankle joint) can cause increased stress and therefore pain in the knees. Pain due to malalignment of the foot and ankle is often confused with osteoarthritis. The use of custom molded orthotics or pronation-control athletic shoes often off load the pressure on the knee and may allow for pain relief in these cases.

Common treatments
Many patients are treated with non-steroidal anti-inflammatory medications (prescription strength Naproxen sodium or Ibuprofen, Celocoxib, Meloxicam, Diclofenac) and similar medications, mostly in pill form. The Food and Drug Administration recently approved topical Diclofenac, which can be rubbed directly onto the knee.

Physical therapy is key in treating the symptoms of osteoarthritis of the knee.  Patients are treated with modalities such as ice, heat electric stimulation and range-of-motion exercises. Specific exercises such as quadriceps strengthening exercises, wall sits and judicious use of the stationary bicycle are an integral part of the physical-therapy program. Acupuncture and massage therapy have been found to be helpful in decreasing the symptoms of knee osteoarthritis.  Swimming and aqua-therapy have a positive effect on the range of motion of the knee and also can decrease pain.

Should the above treatments fail to alleviate the pain,  patients can be treated with steroid injections or the more natural hyaluronate injection.  Hyaluronate is a base product of cartilage that increases lubrication of the joint and decreases pain, thus potentially avoiding surgical intervention. These injections are given once a week for three to five weeks, with the impact lasting six to 12 months.

Often, arthroscopic surgery is recommended if the arthritis affects primarily the space between the knee cap (patella) and the thighbone, which is known as patello-femoral syndrome. Arthroscopy is usually a same-day surgery with a four- to six-week recuperative phase. If the space between the leg bone (tibia) and the thigh bone (femur) is significantly narrowed, a total knee replacement is recommended.    

Dr. De Costa is medical director at Aria Apa and Wellness Center L.L.C. (www.brooklynspa.com) and Rehabilitation Medicine and Sports Services P.C., in Brooklyn, N.Y. (www.remass.org).

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