Knee Osteoarthritis: Which Treatments Work and Which Don't?


Treatments for knee osteoarthritis (OA) range from pills and physical therapy to joint injections and surgery. Deciding which treatments work can be difficult for patients and physicians alike. In this article, we'll discuss the latest guidelines from the American Academy of Orthopaedic Surgeons (AAOS). AAOS is the largest national association in orthopedic surgery and these guidelines represent as close to a consensus as one can get on this controversial topic.

First, let's briefly talk about how physicians evaluate treatment options. The mantra that today’s physician abides by is that of Evidence-Based Medicine. That is to say that every decision and recommendation made by a doctor must be rooted in the best available evidence. So while a specific treatment may work for a handful of people, a physician must take into account the information from all the published studies of that treatment in order to conclude whether there is sufficient evidence to recommend it. Similarly, this article considers the sum total of the best available evidence.

Treatments That Work

  1. Weight Loss: This should be numbers 1, 2 and 3. If you have OA of the knee and have a body mass index (BMI) of over 25, losing weight is your best option. Your joints will thank you. It is perhaps the only option to fundamentally improve your symptoms long term, preserve your cartilage, and alter the trajectory of your disease.  Besides your joints, your body will thank you too due to the decreased risk of heart disease, diabetes, and a slew of other health problems.
  1. Exercise, Activity, Physical Therapy: The AAOS endorses “self-management programs, strengthening, and low-impact aerobic exercises”.  In short, the AAOS means that if you have OA, you should keep moving and keep active. This is true as long as the activity does not involve physical impact on your joints. Pounding the pavement with a 20 mile run is ill advised. Low impact exercises that are the best options for people with OA include swimming, cycling, and walking. Physical therapy will accomplish the same goals of motion/activity, but will be a more expensive way to do so.
  1. Non-steroidal Anti Inflammatory Drugs (NSAIDs): There is strong evidence to say that NSAIDs work. These medications provide effective pain relief and alleviate the inflammation that is a large contributor to the symptoms experienced by patients with OA. This should be your go-to pain management medication unless you have certain medical conditions that make NSAIDs a poor choice. The AAOS also endorsed Tramadol for a similar purpose.

Treatments That Do Not Work

To be more accurate, these are treatments where current evidence has suggested that these treatments are not effective.

  1. Acupuncture: While acupuncture may be relaxing, evidence shows that it will not help your arthritis. This is not entirely surprising. The fundamental problem behind osteoarthritis is the wearing away of cartilage, and no needle regardless of placement will help regrow that cartilage.
  2. Glucosamine Chondroitin supplements: This one is upsetting for the thousands of people that have been taking glucosamine-chondroitin supplements. Unfortunately, there is no evidence to show that this works. From a basic science standpoint, it makes sense that these supplements are not effective. The cartilage lining your knee joint receives most of its nutrients from the surrounding joint fluid, called synovial fluid. In order for glucosamine chondroitin to work, the active ingredients that are absorbed through your gastrointestinal system would have to reach a very high concentration within the synovial fluid. There is simply no evidence that this occurs.
  1. Hyaluronic Acid Joint Injections: Hyaluronic Acid injections (Brand names- Synvisc, Euflexxa, Hyalgan, Orthovisc, Supartz) are a common non-surgical intervention for moderate to severe osteoarthritis. The theory is that this substance lines the knee joint, and helps lubricate movement. Whether this is an effective intervention is a controversial topic. Some studies suggest mild effectiveness. The AAOS concluded that the majority of evidence currently suggests that this intervention is not effective. Furthermore, these injections are associated with risks of adverse reactions including infection and inflammatory reactions that can lead to hospitalization.

The AAOS guidelines make a total of 15 recommendations. Please visit the AAOS website for the full guidelines. These are controversial topics and strong opinions exist regarding the effectiveness of many of the medications discussed. The AAOS guidelines do not provide strict rules for treatment, instead they provide general guidelines intended as a starting point. Each patient is different and needs a tailored approach to optimize treatment. The art of medicine involves incorporating clinical guidelines and best available evidence with a physician’s clinical judgment and patient preferences to choose the best treatment option available. 

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