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Ask a sports doc: Knee pain

“Ask a Sports Doc” is a new quarterly editorial series run by the residents at David Grant USAF Medical Center’s Family Medicine Residency Primary Care Sports Medicine Clinic under the direction of Dr. Henry Lau, (Col.), MC.

Dear Sports Doc,

I heard recently that steroid injections for my knee might be damaging but they seem to be the only thing that helps with my knee pain. Should I keep getting them?

Sincerely,

Can’t Walk

 

Dear Can’t Walk,

You may be referencing a May 16th article published in the Journal of the American Medical Association. Researchers from Tuft’s University compared the effects of steroid or placebo saline injections of the knee between two groups every three months for two years. They were looking to see if there was any difference in pain, or the volume of cartilage between the two groups at the end of two years.

Results showed there was no significant difference in pain between the two groups, but that the volume of cartilage had significantly decreased in the participants receiving steroid injections when compared to those who received saline injections. This is not surprising as it is known that prolonged use of joint injections with steroid can hasten the progression of arthritis. Thus these injections are not offered as a cure for arthritis, but as an aid to relieve pain and allow for increased activity.

This article fails, in my mind, to address the efficacy of steroid injections for patients in the timing of pain assessment. Researchers evaluated each patient’s perceived pain at the beginning of the study, every three months prior to each injection and at the end of two years. What would have been more informative would’ve been to assess pain scores four to six weeks after the injection, as this is when most patients receive peak benefit from a steroid injection. The effects usually wear off three to six months after the injection.

In short, this article does not support the use of corticosteroid injections for the treatment of symptomatic knee osteoarthritis. The American Academy of Orthopedic Surgeons clinical practice guidelines state, “There is inconclusive evidence to recommend for or against the regular use of corticosteroid injections for knee pain related to osteoarthritis.”

However, if you find benefit from the injections and want to continue, you will likely see benefits from these injections over the next several years. You will also likely experience hastened loss of the cartilage of your knee. As of yet, there is no data which indicates how much cartilage loss a person must sustain before they notice an increase in pain, decreased level of function or range of motion of the knee.

Other treatment modalities which have good evidence for improving the pain and decreased knee function caused by osteoarthritis include: supervised or home-based rehabilitation programs, regular low impact aerobic activity (such as walking, biking or swimming) and strength training. Losing as little as five to 10 percent of your body weight can decrease pain by up to 40 percent. Taking non-steroidal anti-inflammatory agents such as Ibuprofen or Naproxen can help. Finally, you may consider total knee replacement.

There is no specific age cutoff for undergoing knee replacement. Most patients are between the ages of 50 and 80. Reasons for pursuing surgical treatment include: severe pain with everyday activities such as walking, climbing stairs or getting in and out of a car, failure for pain to improve with appropriate non-surgical interventions, moderate to severe pain at rest or significant knee deformation or misalignment. Major risks of knee replacement include bleeding, blood clots to include pulmonary embolism, infection and failure to improve pain.

Some other therapies which have not been shown to have significant benefit in clinical trials but under certain circumstances and in specific patients may be tried include: the use of knee braces, medications like acetaminophen, narcotics, glucosamine, chondroitin, acupuncture and hyaluronic acid injections.

Osteoarthritis of the knee is a progressive disease which results from wear and tear of the joint overtime and from trauma such as an ACL tear. As of now, there is no way to reverse the damage of the disease. The goal of treatment is to decrease pain to the point you are able to perform the activities you enjoy. No one treatment is right for everyone, and a treatment which works now won’t necessarily continue to work in the future. However, weight loss, low impact activity and strength training can delay the progression of osteoarthritis and can help overall health and wellness. Be sure to include those basics in your plan for healthy knees.

Matthew C. Hess, MD


Have a burning sports injury related question? Drop us a line at 60AMWPA@us.af.mil, attn: “Ask a Sports Doc.”

Dr. Matthew Hess, (Capt.), MC is a recent graduate of DGMC’s Family Medicine Residency program. He completed his medical education at the Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, and is headed to Fairfax, Virginia, to pursue a one-year primary care sports medicine fellowship with the Virginia Commonwealth University-Fairfax Sports Medicine program.