As reported by the New Britain Herald, March 30, 2005.

Long Road Ahead for Those with Knee Problems

By Tricia Stuart

"When it comes to knee problems, conditioning and physical exercise, and maintaining your weight is probably the number one thing you can do to improve," said Bob Arciero, professor of orthopedic surgery at the University of Connecticut Health Center . "If you enjoy extreme sports and collision sport, then your risk to knee injury and joint problems is a given."

Arciero is a sports medicine doctor who sees patients with knee and shoulder problems.

Arciero works with patients to alleviate or prevent knee pain, when it occurs, and rarely recommends surgery.

We try to have patients not have surgery or to delay it, and if they do, then we send them to doctors who do knee surgery," he said.

There are a number of reasons why people have achy knees, he said. Usually younger people don’t have complaints, but middle aged and older patients may have problems with their knees.

"They can’t recall a specific traumatic event. It may be cumulative, after moving furniture, or gardening for six hours. People say their knees are more painful and growing stiffer. Most of the time symptoms are only in one knee. Twenty to thirty percent of people have problems with both knees," Arciero said.

Most of the symptoms are from early to mild osteoarthritis. There may be a breakdown of the lining in the cartilage in the knee. All joints are lined with cartilage that helps the joint move freely through the arc of motion. "This surface is even more friction-less than ice," he said.

Doctors do not usually know what causes that breakdown. There may not be a specific precipitating event.

"It could be a breakdown over time, it could be aging, it could be trauma. Changes occur in bones that promote achiness and loss of motion. When the doctor says the patient has bone on bone, it means that the space we should see on the X-ray is gone. The joint lining material has been worn away so the bones are rubbing against each other. The gliding surface has worn away," he said.

When that coating, or articular cartilage, is gone, it provokes inflammation and the knees can make a lot of noise. "A lot of joints make noise and they don’t hurt. Not all popping and cracking means there is a problem. Arthritis isn’t necessarily present," Arciero cautions.

One of the things people can do when early symptoms arise, Arciero advises, is to stay in good shape. "I’m not talking about being a marathon runner." He advocates non-impact light exercise that uses the full range of body motion, such as using a Nordic track, swimming and walking; the key is exercise that maintains flexibility. He says physical therapists teach patients range of motion exercises.

"Its important not to lose range of motion, to strengthen muscles around the knee, and keep weight down," Arciero said.

Glucosamine chondroitin sulfate, an over the counter medication that is found at health food stores will help some patients. "I tell patients to try it for two to three months. If there is no effect, discontinue it. If it helps, continue it. There are no known side effects to using it," he said.

For severe pain, he recommends anti-inflammatory medications. Vioxx was removed from the market by the FDA because of risk of heart attack, and Celebrex is under scrutiny, he said.

Patients who are over 35 may have knee problems and stiffness. It’s unusual to see younger people with problems. "If there was a knee injury when a person was younger, you could see problems 20 to 30 years later," he said. That trauma may have precipitated some arthritis in the knee. Surgery helps patients who have surgery in their teens that removed the meniscus (shock absorber in the knee between two joint linings), for a long time, but in later years, some secondary loss of joint lining may occur.

Fifty percent of Arciero’s patients come in with a sore knee, perhaps caused by gardening or hiking; they can’t tell him about a specific traumatic event that caused it. Thirty to forty percent know what traumatic event occurred, and 15 to 20 percent have a significant knee trauma that has produced arthritis.

"We can get the majority of patients through this," Arciero said. "Occasionally symptoms will escalate and then we will do invasive surgery."

If nothing works, especially for people who are older, beginning in their 50s, the doctor may inject the knee with cortisone. Arciero has had results for up to two years with cortisone. Three to five injections of cortisone, over the course of a month or so, will buy the patients some time if they have mild or moderate arthritis, but it won’t work for severe arthritis.

The caveat is that cortisone, if used repeatedly, can be dangerous. Two to three injections don’t pose a high risk, but for patients with diabetes, cortisone can cause elevated blood sugar and must be watched carefully by a doctor. Cortisone can cause an inflammatory reaction in some patients, and can make them feel temporarily worse, before they feel better. If cortisone is abused, it can cause a breakdown of the cartilage. It blunts inflammation and may help the patient’s pain "but may abort a normal healing response."

Arciero points out, "This is not an anabolic steroid; it is anti-inflammatory." It is not the same cortisone, or steroid, that causes athletes trouble.

If the arthritis escalates, he will inject the knee with viscosupplementation, which rep-laces the lubricant in the knee, and has a positive effect on the pain and reduces inflammation. Viscosupplementation may cause an inflammatory reaction, temporary swelling, and could cause an infection. Unlike cortisone, it doesn’t raise blood sugar, but it is expensive: one series of three to four injections costs $500 to $1,000.Most insurance covers it and Arciero doesn’t use it very often. "It either works or it doesn’t. All of these things might not work, but we can help patients in most cases."

"If the patient is quite miserable and can’t walk, and there is some joint deformity, partial or full knee replacement surgery is recommended," he said.

"Unless the patient is having locking and catching in the knee, we don’t use arthroscopy (removal of torn pieces of the cartilage or cleaning the knee out). Patients with locking and catching will feel better. If it becomes bone on bone, then they are a candidate for joint replacement."

These problems, if they occur, usually occur in middle aged or older patients. However, Arciero is seeing younger patients now as well.

"I’m seeing more severe arthritis in younger patients who are morbidly obese: patients who weigh 30 to 60 pounds more than they should," he said. "Obesity increases osteoarthritis risk in weight bearing joints, especially in the knee."

To avoid osteoarthritis, Arciero recommends staying physically active; maintain weight as a preventive measure; do low or non-impact exercises like tai chi, yoga, bicycling, walking, swimming, and low or no-impact physical exercise three to four times a week; and eat a proper diet.

"Morbidly obese people will have problems with arthritis. If they have a strong family history of knee problems, there isn’t anything we can do."