1) LOADING TISSUES
For many years, patients with arthritic changes or “degeneration” in their knees have been told to limit their activity, especially weight bearing activities. Depending on the severity of the case and other health factors, moderation of some activities is usually appropriate, but in almost all cases to have a patient completely avoid and fear lifting and loading through their knees could be doing more harm than good. More and more research is available to show the positive mechanical, neural, and chemical benefits of repetitive loading of cartilage tissues in the body.
This STUDY from Madej and Colleagues in 2016 is a good representation of the underlying processes that occur when we move and work out. To summarize it in a super simple way, when we load and put pressure through our cartilage there are chemical messengers released that signal various growth factors. When you stop loading cartilage, a number of changes happen. There is an increase in expression of types of degrading enzymes, a decrease in the growth factors in and around the cartilage, and negative mechanical changes to the cells themselves (chondrocytes) that actually produce and modify cartilage. In a nutshell, this is what we see clinically as the beginnings of osteoarthritis, and this is what researchers are observing in animals and humans when there are prolonged reductions in the way we move and load our tissues.
There is evidence that at any stage of arthritis the joints benefit from appropriate loading and signaling of the tissues. For those with advanced conditions, the type, volume, and intensity of exercise and loading will be different. It's important to consult with a knowledgeable healthcare provider about exercise and various treatment options, and which will be the most helpful.
Remember too that just because your imaging shows arthritic changes, or decreases in the amount or quality of cartilage, it is not a guarantee that you have to have pain or dysfunction. Most of us will have these changes on imaging at some point and have zero pain or dysfunction, and many patients who are treated conservatively for these conditions return to pain free activities, which begs the question...was it 100% the source of their pain in the first place?
2) CAUTION WITH STEROID INJECTIONS
For many years patients have also been given steroid injections into the knee joint itself in an effort to decrease inflammation and pain. Many quality studies are finding though, that among patients with osteoarthritic knees, repeated steroid injections over a number of years are bringing little to no long-term pain reduction, and actually increased the loss of cartilage in the joint.
A STUDY by McAlindon and Colleagues in 2017 followed 140 patients with painful knee osteoarthritis over a 2 year period. Every 3 months one group received triamcinolone injections (a common type of steroid injection) and one group received an injection of saline (the control group). At the end of the 2 years, the group that received the steroid injections had significantly greater cartilage volume loss and no difference in knee pain.
There are a number of theories about why this may be happening. Some point to the fact that healthy inflammatory reactions trigger the body’s immune system to release growth factors, and by limiting overall inflammation you are limiting the ability of the cartilage to respond to signals from it's environment appropriately (like from loading activities). Another theory is that cartilage already has poor blood flow, and the steroid shots may decrease this effect even more. Lastly, there is some evidence for changes in local hormones that help regulate cartilage and other tissues in the joints.
The honest answer is we don't know yet, and at times when the negative effects of excessive inflammation outweigh the negative effects of the steroid shot, it may be appropriate in moderation. Unfortunately, the amount that the procedure is used and the cases it is typically used in, far outweigh what should be considered "good practice." Caution should be taken by patients seeking out treatments for knee pain. It's ok to question the treatment options proposed to you and ask to at least try a quick bout of conservative care first.
Interestingly, exercise in itself can have significant anti-inflammatory effects on joints, without the risk of increasing cartilage loss. The key is finding the right activities and movements for your individual knees and lifestyle.
To put overall movement and activity into perspective, consider this STUDY from of over 1,800 adults who had or were at risk of knee arthritis. Over two years a number of factors including pain and overall function were tracked, as well as the number of steps taken per day. The results showed that one hour of loading activity per day (approximately 6,000 steps) helped to improve knee arthritis and prevent disability.
This is likely due to a variety of factors including better metabolic and inflammatory control, improved blood flow and oxygenation of tissues, exercise induced analgesia (pain control), and increased tissue growth factor chemicals as described above.
An important note is that you don't have to jump to a random number of 6,000 steps to start to reap the benefits. The researchers recommend that people with mild to moderate knee OA start with just 3,000 steps per day and try it on days when you have little or no pain, then begin working up from there.
So to sum it up, we have a lot more to learn, but what we know currently is that for most people with knee osteoarthritis, arthroscopic surgery and injections may need to be saved for the extreme last resorts, and a global assessment of individual variables should be addressed by the patient that will affect the long term health of the joints.
This can begin with knowledge of loading cartilage tissues in healthy ways, avoiding unnecessary procedures that might increase risk of knee OA and cartilage loss later in life, and making sure you are addressing lifestyle factors that incorporate enough activity, strength, and range of motion activities on a daily basis.
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