Knee Arthritis – What Is It & What Can I Do About It
/in Podcast/by dmiddaughHello El Paso! Welcome to the Stay Healthy El Paso Podcast. I'm your host, Dr. David Middaugh, physical therapist and the owner of El Paso Manual Physical Therapy. Our topic today is going to be about knee arthritis. Specifically, we are going to figure out what it is, and what can be done about it.
These are questions we get in the clinic. The time people come in with x-rays, sometimes MRIs, and they have been told, by a doctor or they have read their own X-ray report, and they found out that it says, the dreaded words knee arthritis or osteoarthritis specifically.
But let's talk about what is knee arthritis.
We are going to answer these questions today. What is knee arthritis? How does knee arthritis happen? What types of treatment do people do for knee arthritis? And how much can I improve my knee arthritis? Is it possible to be normal? Let's get going with the first question.
What is arthritis?
Arthritis is actually, it's kind of a misnomer, there are different types of arthritis. The most common by far is osteoarthritis. We are going to assume that that is what we are talking about. I'm not a specialist in other types of arthritis, like rheumatoid arthritis, psoriatic arthritis and there are other types as well. Those are the types of arthritis that you want to see a rheumatologist for. You probably will need to get a different kind of treatment then what we can offer. It's definitely not mainstreams. It's its own specialty.
For the sake of knee arthritis in this podcast episode, we are talking about osteoarthritis. But I'm going to say arthritis a lot, just because I know that's what most people say. They say, “Oh, it's my knee arthritis”. Hardly anybody in the general public says osteoarthritis.
So, what is knee osteoarthritis? Knee arthritis is changes that happens on the surfaces of the joints within the knee. A lot of people don't know this, but your knee actually has three joints in one. It's the connection between the thigh bone, the femur, and the shin bone, the tibia. That's one, and then there is a connection between the kneecap, also known as a patella, and where it interfaces with the femur, the end of the thigh bone. So that's a patellofemoral joint.
Then you have an A joint, off to the side, that people don't typically think about as being part of the knee., but it is. It's called the tibial fibular joint. You have two bones in your lower leg, the tibia and fibula, and they connect in two spots to each other. Down at the ankle is one that makes up the ankle joint and then up at the knee. They connect as well.
In some people, that can be a little problematic, but that's a less seen injury, and for the sake of arthritis, we are going to focus on the kneecap and the femur, the thigh bone, and the tibia, and the femur as well.
Knee arthritis is when the surfaces of the kneecap, the backside of the kneecap, and the surfaces of the thigh bone on the end of the thigh bone, where it's at your knee, and then also on the top of the shin bone. When those surfaces begin to change over time, and when I say time, I'm talking about years, even decades, they change, and they decrease congruency. Meaning, how well they fit together. The surfaces are aligned with cartilage.
Cartilage is important because it's a really smooth tissue, and it eliminates friction. It reduces friction tremendously inside of a joint so that your bones can move on each other without popping, grinding or clicking.
If you have trouble with your cartilage, then it tends to lose its smoothness. It's hydration as well. We'll talk about that in a second, and how easy the joint moves and that's why you might get popping and cracking inside the knee joint. If you have arthritis type problems.
Arthritis is not a disease if you will, it's not like something that you catch like a cold, or an infection. I just want to clear that up, but some people might not know, and I want to just clear that up for them. It's something that happens over time. As we age, and as we use our bodies more. Now I said as we age, but I just want to make it clear that you can be older, you can be elderly, you can be into your 50s, 60s, 70s, 80s, and beyond, and still have fantastic knee health. Despite your x-rays showing that you have arthritis.
Let me say that again. You could have pretty bad looking arthritis on your X-ray. You can be older, and you can still feel great in your knees. I need to say that to you because many people don't associate those things. The proper way to think about arthritis, knee osteoarthritis, is it's a normal part of aging, just like we get gray hairs, and wrinkles on our skin, on the inside of our bodies, our cartilage changes over time in a way that isn't always the best.
The best example that I could give you, if you think about an old vehicle, maybe it's in great condition. For example, I have a neighbor, down the road from me, that collects 1957 Chevy's, I believe it's 57. I'm sure he correct me if you heard this, but he's got three of them, and he keeps them in great shape, but I'd be interested to see under that vehicle. If you poke your head under that car, you probably will see some spots of rust here and there, just because that's what happens to metal over time. Especially metal was used back in the day.
Now that rust is similar to arthritis happening in our body. It may not be detrimental to the function of the vehicle, those vehicles might still run just fine, if there are just spots of dust of rust here and there. It won't affect the structural integrity of the frame of the car, the struts, the shocks, the bolts, everything that builds the car. All the components of the car should operate just fine if you just have some rusty spots here and there.
But think about this, if that rust was so bad that it's starting to cause a hole in pieces of the metal. It's starting to bend because the structural integrity of the metal is being affected, because there is so much rust, then you have a serious problem. Then you may not want to drive around that car. You might be about getting it fixed somehow.
Same thing with arthritis. If the arthritis is so bad inside a knee joint, then it's going to start affecting the ability of that person to walk, to stand, to sleep, to do everyday activities. But if you get a little bit of arthritis on your X-ray, it may not actually be the source of your knee pain, it may just be that, going back to the car example, that you need new tires, or you need an oil change, or that something else needs to be fixed. It may not be the reason why your car is not working, right?
Going back to the knee, a little bit of arthritis may not be the reason why you are hurting, or why you are having any problem. It could be a bunch of other things. It's not a good idea to associate your age with arthritis, and with your ability to improve. I think that's really important for you, because let’s say you are in your 60s or 70s, or older, or even younger, and you have an X-ray and you found the dreaded words in the report knee arthritis or the doctor told you that you are developing knee arthritis. Another thing that people will say the doctors will say is that they have knee degeneration, or degenerative joint disease.
Diseases a misnomer, they actually talk in the medical field about getting rid of that term degenerative joint disease because it leads you to think that it's a disease, like something that you catch, or that there is a medicine for that cures it, and that's not the case. It's just, it's wear and tear, essentially on a knee joint. The cool thing about the body, though, that's different from a car, is that it can heal our bodies, or living tissues where obviously cars are not.
If you put the body in the right environment, if you give it exactly what it needs, it should heal. The predominant thinking in the medical field is, that once you have arthritis, that it only gets worse over time, and that it doesn't heal. If you have pain, especially knee pain from this arthritis, then you are only going to get worse. Some doctors will even go so far as to say that, you might need a knee replacement in five 5 or 10 years, or however many years, because that's what they typically see. They typically will see people that come in for knee problems, and physicians are doing their best, they are helping them out with injections and medications, and might make recommendations for surgery. That's what they are trained in, and that's what they are specialists in. So, that's how they think to help you out.
Sometimes I even have clients that go to physical therapy, or get other sorts of treatment, and don't get better. I always question what was done? What do they do? Anybody that is therapists, the physician, the surgeon, was it the best thing for your situation? Did they check certain things in your knee that needs to be checked so that you can properly get better? There are all kinds of reasons why a knee can hurt, and arthritis is just one of them.
Let's talk about that, let's answer the question of how does knee arthritis happen? How does it progress? I mentioned the words wear and tear a second ago, and you hear that a lot in the medical field, especially patients that go visit their doctor and get an X-ray. The common way that doctors will explain what's going on in their knee is, they'll say you have wear and tear, and what that tends to mean is that there is cartilage that is thinner than it's supposed to be. So that's where it's worn down, and there might even be spots where there are tears in the cartilage.
Some doctors will mention the words “you have NO cartilage in your knee”. I want to clear that up, a mind picture that people get, whenever they hear these words, that they have no cartilage in my knee. They think that the entire surface of cartilage, on the back of the kneecap, or on the end of the thigh bone is completely gone. That's extreme. I can tell you right now, if you have been told that, that you if you are going to walk, your knee would be locked, you wouldn't be able to bend it, or straighten it out very much at all.
Maybe you do have some loss of motion and some locking here and there, but that could be for a slew of other reasons. Your knee would literally not move at all, it would be like trying to undo a very, very rusty bolt. Like it would be extremely stuck, and if you pry it loose, all this dust would fly out. You might even break the bolt where it's attached to and your knee would not function normally or anywhere near normal.
If you had complete loss of cartilage on any surface of your knee joint. What is more likely to be the case, if you have been told that you don't have cartilage is, that there is a spot on your kneecap, on the back of your kneecap, or on the end of your thigh bone, where the cartilage has worn down enough to go all the way through down to the bone.
Another phrase that doctors will typically use is, it's bone on bone. The knee joint is bone on bone, and they are not talking about the entire surface. We are talking about a single spot, usually in a severe case, where the knee joint is bone on bone, and once people get that, the picture in their mind is that there is no cartilage in there, there is no chance of it coming back. Then they start going down the thinking of I need a knee replacement.
In the root of the problem, what tends to make knee arthritis progress faster than it normally should, because you are going to get it as you age anyway, it may not be painful. But in people that are in their 30s 40s, or 50s, or some people in their 20s, as well, they have some severe knee pain. Usually, it's been going on for a while and you may have gotten x-rays and your cartilage is worn down, and maybe even have a spot that's bone on bone. What has been happening to you more likely than not, the most common thing that I see happen to these people is the mechanics in their joints. In other words, the way that the bones move on each other, has been off for a long time, and it's causing certain surfaces of the joint to rub on each other inappropriately.
It's causing extra friction, extra pressure in those areas where the cartilage is worn down or torn, or it's bone on bone. That's not the way that motion is supposed to happen in your knee. As a result, you have worn it down faster than it should. The good news about this is just like our skin and other tissues in our body. Cartilage can develop scar tissue, and scar tissue isn't a bad thing.
A lot of people get all worked up over having too much scar tissue and, and it being you know, you have to break up scar tissue I hear about that as well. But the reality is that scar tissue, when it's laid appropriately in a tissue, it's about 60 to 70, sometimes even 80 to 90% as strong as the original tissue. That's pretty darn good. In my opinion. That's way better than getting stem cells or PRP injections, where you are looking at possibly regenerating a small percentage of the tissue. I'd rather have scar tissue all day and fix your original root problems so that I'm not going to wear down my scar tissue as well.
How do you generate scar tissue though? Well, in the kneecap, it has to heal slowly over time. In the end of the thigh bone, cartilage just comes on very, very slowly, it heals at one of the slowest rates of all the other tissues in the body. In somebody who has bad mechanics, it has been going on for a long time. They wear down the cartilage.
What I often find if we are talking about the kneecap on the thigh bone, let's talk about the muscles for a second the thigh muscles on the front of your thigh. Those are called quadricep muscles, quads for short. People that have long standing knee arthritis and pain on the front of their knee or deep into the knee. They tend to have very over dominant quad muscles, very strong quad muscles.
I had a client not so long ago that we started seeing for a knee problem and she told me she's been exercising and fit for whole life and she's in her 50s. She is still pretty young to have knee arthritis problem. But she's gotten there because she's been so active, playing sports, going to the gym five days a week and getting on the treadmill running. She's convinced that she needs to stay active and healthy so that she can be healthy into older age, but she's worn through cartilage.
I asked her if she does squats in the gym and other leg exercises. I said when you go do your leg days at the gym, where do you tend to get most sore from, or where do you tend to feel the muscles work the hardest. She said hands down my quads. I have always worked on my quads. I've always been proud of having big quads, big thighs, strong, quad muscles. Then I asked the question, how about the hamstrings? How about the glutes, she said, rarely ever do they get sore, rarely ever do I work them out? I always get on this machine and do this exercise. I do the leg press. I do the squats. I do this. I do that.
I went through deep in detail through every exercise she would regularly do, and she confirmed that she always felt her quads work the most. When I told her what I discovered, I tested everything out in her in her legs to figure out what the root problem of the of the knee arthritis was. I told her you have got some of the most dominant quad muscles I've ever seen. And the evidence is there. From what you are telling me that you have worked out your quad muscles way too much and unknowingly have neglected other muscles that should be in balanced with the quad muscles.
When those quad muscles are as dominant as yours, what happens in the mechanics at the knee joints, those quad muscles all attach to the kneecap. Which causes them to shorten. The stronger the muscle is, the more it shortens just at rest. That's a known fact. So, it puts the kneecap against the end of the thigh bone the femur harder. Without even doing anything, the kneecap will be pressed up against the thigh bone. And that increases the pressures and it doesn't allow the cartilage to recover to rest and be able to regenerate itself and be healthy.
Then when she goes to exercise, when she's not doing any more, we've fixed a lot of things in her. But when she was going to go exercise, she was further strengthening her quads and in further increasing the forces in during the exercise itself. She was getting a lot of grinding, popping clicking in her kneecaps, which was just if you think of the cartilage surfaces, they are just being pressed against each other way too hard.
That's how arthritis happens over time. If you can imagine this woman exercising five days a week, doing things that involve her legs, pressing that cartilage up against itself, way harder than it should, and then doing that over the course of years, over the course of decades. She's in her 50s now, she said she's been active ever since she was in high school, playing high school sports and she never quit.
Occasionally, everybody goes through seasons of life where they might back off on exercise, they gets sick, the holidays come around. In her case, she has two or three kids. So things change in life, but she always came back to exercising. She was pretty consistent with feeding into this muscle imbalance and putting too much pressure on her knee cartilage. She developed knee arthritis.
But how do we undo this? Let's talk about the types of treatment that people do. First, I'm going to go into the types of treatment that are commonly done. What people tend to encounter first, whenever they visit somebody in the medical field. In our opinion, what I think we can do here in our office, I'll pass them a physical therapy to help people for the long term so that this is getting better for months and years, and possibly the rest of your life.
The first thing that people will do at home is use some sort of over the counter pain medication, Tylenol, ibuprofen, or they may rub what's called an analgesic lotion or gel. we are talking Bengay, Biofreeze, Tiger Balm, one of those types of lotions that take away pain.
Both of these things are temporary. They don't make your muscles stronger, they don't fix the way the joints moving, they don't fix the mechanics, which is a root problem for most arthritis problems. It can feel better, it can possibly help you sleep better at night. It may allow you to get through a few days of where you need to be on your feet a lot or use your leg a lot. And that's cool, but it's not a good long-term plan.
The next thing that people will do typically, they'll visit the doctor and the doctor, with best intention, will offer a prescription strength medication, they may offer an injection for the knee as well. Those two things, prescription strength medications and injections, can definitely help the pain but just like with the over the counter stuff, the things that people try at home, they do not help the pain for the long term. It's just short term. It just helps, instead of just a few hours or a day you might get relief for a few weeks, or maybe even a couple of months with another Injection. That might get you through a tough spot.
Other things people try at home, they get a knee brace. It's a hit and miss where some people swear by it, and say they feel better when they have a knee brace on, other people say they don't. The trouble with the braces is, there are no such thing as a comfortable knee brace. Everybody fights with them, they have to constantly shove them up. Everybody's legs are shaped differently, and no knee brace is truly one size fits all. They might say that on the knee brace, but everybody's just shaped differently, and they fit everybody differently.
The other thing with knee braces is, you ideally don't want to be in it forever. You need to have a plan to fix your knee problems, so you don't have to worry about being in a knee brace forever. You have to have some way to get out of the knee brace.
Other things people try at home is rest it. Which is great because your inflammation will go down. The trouble with that is, once you get back to being active or doing your normal routine, you are going to be grinding those knee joint surfaces again and aggravating the knee arthritis.
In extreme cases of knee arthritis, that joint just doesn't move as good. The joint doesn't bend as well and doesn't straighten as well. We see some elderly clients here in the office where we flat out tell them, you are not going to get much more motion than what you have already. I can work on you here. But maybe you'll get 50% better, maybe 70% better, is a good outcome. But if the knee arthritis is very advanced, then there is no guarantee that it's going to get completely better.
The only way to get beyond, the motion that they currently have, if they are limited, is to look at getting a knee replacement, but that's a whole other process, a whole other story. If you are very elderly, your health has to be taken in consideration as well as your ability to tolerate the recovery.
It's a massive surgery if you think about it, getting a knee replacement, they are literally chopping the end of your thigh off, your thigh bone, and the top of your shin bone, and replacing it, they are putting metal parts in there and other parts. They have to deal with your kneecap as well on the front end, and then they have to reattach everything. So you up and then you have to begin to learn how to use it, and walk on it. The cool thing about it is that surgery has been refined over time and if I had to get one at this point in time, I would be confident getting one.
I think the surgeons out there do a phenomenal job with it. But that's pretty last resort and ideally if you can save your knee from getting to that point, your own natural knee is the best thing you want. I know surgeons will tell you preserve your knee health, try to avoid getting a knee surgery of course but if you have to have it done. It's actually not a bad surgery to get. But ideally, let's avoid it.
Now let's talk about how much is possible to improve knee arthritis. Depending on the severity of it and how much it's limiting you. You may be able to get quite a bit of improvement. If you are thinking about your X ray that you got not too long ago, and they said it was, moderate or severe.
If you were to get an X-ray after doing some treatment, it may not change that much. I think the best scenario you are looking for as far as x-rays improving is that it stays the same, that doesn't get any worse. The changes that happen occur slowly over time. So you are not looking to have a clear X-ray.
What is way more likely to be the case, you feel better and that you can move better. We see that here in the clinic all the time. When I first meet a person here in the clinic, who's coming in to get help with any arthritis problem, after talking to them, figuring out their story, getting all the details that we need, checking them out by hand, feeling their knee joint, looking at muscles, all the stuff that we have to look at, I'll make my recommendation and I'll tell them, hey, realistically, we can get you 90% better, which should be enough to get you back to exercising, and doing certain things that don't aggravate it. You'll have to still baby it at times here and there. But that should be enough to allow you to enjoy your life just fine, and, be with your family, play with your grand kids, be active, be able to travel and be on your feet for a long time and you'll be fine.
In severe cases, then we are telling people, hey, we are looking at a 50% improvement. In those types of patients, usually their doctors have told them that they won't operate on them, that they are high risk. They can't have a knee replacement done. It's this or nothing, pretty much they don't want to be at home stuck taking pain medications all the time. So, they improved tremendously and get a lot of mobility back.
In those people, I'll tell them the realistic expectation of just improving about 50 to 70%. It just depends on how they present exactly. The more important thing for somebody who has severe, far gone arthritis, and they are not going to improve more than 70%. The more important thing for them is keeping their independence.
I had a client last year who was a pretty severe case. He could still walk, he could still drive, and he was in his 80's. He could still do a lot of things on his own. But his arthritis flared up tremendously over the holidays, and he just wasn't as active during the holidays. So that's why it got worse. He had lost his ability to walk on his own. He had to hold on to furniture, and people had to help him out. He was starting to use a walker, he had to use a bunch of different things to help him maintain his balance, because it was so painful for him to stand up and walk after treatment.
He couldn't straight out his knees all the way, he was lacking about 10 to 15 degrees in both knees. We got them maybe down to five degrees, six degrees, I forget the number exactly. But his knees, when straighten out all the way, they were pretty stiff at the end. I told him that's the expectation. We are not looking to have you strain out your knees all the way if you haven't been able to in years and years and years.
But he felt notably better his big concern was he could sleep better. He could stand for longer, he could tolerate getting himself in and out of cars without having so much help. He felt like he could take himself to the bathroom. That was a big deal for him. It's embarrassing to have your family help you out with the bathroom. He also could get himself dressed. That was another thing to get himself showered, he felt more confident being able to move around.
Being able to improve that small percentage, even if you are not looking at getting 100% better, because it's not realistic for you, it can mean the world of a difference, and keep you in a much happier place where you don't have to rely on family seeing you naked, or having to clean you up after using the bathroom. It's a big, emotional component that people can preserve when their knees are healthier.
If you are not in that type of severe situation with your knee arthritis, it's more mild, you can bend and straighten your knee all the way for the most part, maybe just hurts when you bend it all the way or straighten it all the way. You might have some grinding or clicking in there. There are a lot of mechanical improvements we can make. I can't tell you exactly what needs to be done for your knee right here. There are many factors to look at.
To exactly determine what exercises you need to do, what kinds of hands on work you need. It's it really is its own specialty. But we see people all the time, get back to exercising, get back to running, even impactful activities like running and jumping, they can do that. They have got to learn how to move better, and they have got to strengthen in certain areas. That takes some time and coaching, but it is definitely doable. You can definitely get back to being active again. Being able to kneel is a big problem for certain people, get down to the knee or even getting up and down from the floor. That's a big problem that people face too. They have many issues.
Some people that have had knee replacements already continue to have any trouble after the knee replacement, even they tend to not have as much pain because their knee is artificial. They don't have a normal tissue. But people with knee placements have typically not fixed all the underlying root problems that got them the Arthritis to lead to the knee replacement. They still have very overused quads and muscle imbalances and all kinds of issues that that never were fully addressed.
But at least you are feeling better because of the knee replacement. But because they have limitations and how they are able to bend their knee and use your knee, they have trouble kneeling, they have trouble getting up and down from the floor. And that can be improved a lot of these people, because the last thing you want is to lose your mobility as well as to not be able to be independent, not be able to drive, cook your own meals, do all the things that that you won't be able to do on your own at home.
I've had lengthy conversations with elderly clients that come in for knee problems, and they are pretty embarrassed to ask for help from their kids or other family members with doing some things. It's always tough but when you have to do that you need to because it's potentially dangerous if you don't get help. Of course, they think about where it's going to leave later down the line, am I going to put them nursing home? Am I going to have to have somebody move in with me when I've been by myself, or it's just been my spouse and I and I don't want them to have to hurt their back helping me all the time with putting on my socks and shoes, because I can't bend my knee all the way.
There are all kinds of problems that arise from not having healthy knees. If you are listening to this podcast, and you have knee arthritis, and it's not that bad, I strongly encourage you right now to take care of it before it gets too bad. Find out what treatment you need. I definitely recommend talking to somebody who's an expert in preventing surgery, injections and having to rely on pain medications. But take care of it. Don't let it get too far gone where you have to end up talking to somebody that tells you it's only going to get 70% or 80% better. Ideally you want it to be 99% better, even 100% of possible.
So guys, I hope that podcast explanation explains everything about knee arthritis. What it is and what can you do about it. I hope that we've set some expectations about it. Cleared up some myths about what knee arthritis looks like inside of a joint. And I hope that we can share with you all the information that you need to make the best decision about your knee problem.
Visit our website to find more resources on knee problems. We've got a tips guides that you can download for free. You can get them sent to your email right now if you go to www.epmanualphysicaltherapy.com and you'll see our tips guide there that you can download.
If you go to our blog, you'll find tons of helpful videos and blog information on what to do about any problem. If you think that you want to get in touch with us and get started with working on your knee problem with us, we'd love to help you out as well. You can call us at 915-503-1314 to find out more information. But if you are just at home, you just learning right now that’s totally cool. Absorb all the knowledge, do your research, talk to the right people, and make sure that you take care of any problem. Don't wait. Please don't let it get really bad. I hope you have a wonderful day.
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