Transcription:
Knee Arthritis in Middle-Aged Athletes

Melanie Cole (host): Do your aching knees keep you from performing your best? If you have knee pain but you want to stay active, in shape, and competitive, we're going to tell you here about the many ways you can manage osteoarthritis in your knee. My guest is Dr. Eric Mirsky. He's a board-certified orthopedic surgeon and chair of the Department of Orthopedics at Summit Medical Group in Berkeley Heights, New Jersey. Welcome to the show, Dr. Mirsky. Let's talk about the knee for a minute. What an amazing little joint that carries so much of our weight, such distances in our lives. Eventually, it starts to break down a little bit, doesn't it?

Dr. Eric Mirsky (guest): Yeah, and thank you for having me Melanie. The knee is a biomechanical and physiological marvel in terms of how it's put together and how it functions. It helps us do many of the high-demand and sporting activities that we do, and it helps us stay healthy and active. Unfortunately, the knee is also a weak link in the body, and it does almost inevitably start to wear down and start to deteriorate. Many of us, especially as we get into our 40s, 50s, and 60s, develop arthritic problems about the knee, really degenerative problems. The knee is really the most common joint for degenerative arthritis to develop. It's almost an inevitable part of the aging process.

Melanie: So how do we know a pain in the knee from chronic overuse versus it's starting to degenerate a little bit, develop a little bit of arthritis? Are there certain pains, red flags you can give us?

Dr. Mirsky: The issue of differentiating the quality or the type of pain is very difficult. Our bodies tell us something hurts and tells us to back off a little bit but don't provide a lot of information about the different types of pain. Arthritic pain, most people have a conception of it, that it's dull, it's insidious, it comes on slowly over time, and much of that is true. However, its character at times can be sharp, it can be severe, it can be sudden -- it can be brought to the forefront from an injury. People don't associate arthritis with injury, but certainly it can be. It can be associated with repetitive trauma over time with wear and tear. It's become so prevalent in our society as people stay healthy and active. When you look at participation, more and more of us participate in physically demanding and high-impact sports well into the sixth, seventh, and even eighth decades of life. So the knees take a repetitive pounding over time, and much of the pain and discomfort we develop is a result of that use over time. But there are no specific red flags for that.

Melanie: So we start to feel pain and we come and see you. What are some non-surgical treatments for knee pain? And I'm talking exercise, strengthening, braces, ice, NSAIDs. Give us the whole line of treatments you might try.

Dr. Mirsky: All of the above. We usually start with exercise. The goal is to keep people healthy and active and to make comfortable. Exercises are both home exercise programs, supervised programs, and physical therapy. In general, for knees and for people who are developing arthritic problems, as an exercise, we want to emphasize non-impact types of exercise. The classic exercises that are good for knees are stationary biking. It's really the prototypical one. But stationary biking is excellent. People always ask isn't a road bike good. Road bikes are just considered a little bit more recreational as opposed to stationary bikes are considered a little more exercise because of the impact. Elliptical trainers are excellent, swimming is always good for our joints, any kind of NordicTrack, rowing machine, even weights—leg presses, leg curls, leg extensions—are all good. We also try to differentiate what are called open-chain versus closed-chain exercises, with the closed-chain exercises being something like a stationary bike, where your feet are in a pedal and never come out, as opposed to running, which would be an open-chain exercise. Generally, the closed-chain, non-impact types of exercises are ideal for people who are developing arthritis in the knee, especially during our active years and while we're still active. In terms of home exercises, there's supervised programs, there's physical therapy. And it's really whatever that individual will tolerate and will do. The more supervision, the more therapy which is more assisted for those who are farther along in the process.

Melanie: Dr. Mirsky, when would NSAIDs come into place? When would anti-inflammatories help in the situation?

Dr. Mirsky: Anti-inflammatories are a supplement to an exercise program. They help manage the pain, they have an analgesic effect, and they also have an anti inflammatory effect. And I advise people to take them before exercise or before therapy. They're taken on an as-needed basis, so they are a very useful adjuvant to the physical therapy.

Melanie: What about ice versus heat?

Dr. Mirsky: Ice is much better for knees. Heat is a little more for muscles, ice is a little more for joints, just in general. But ice is always good for knees. I very, very rarely—and only in very isolated circumstances—recommend heat for knees. Ice is very good for knees as an anti-inflammatory. It's a local anesthetic, and it's usually applied after exercise, and it's usually about 20 minutes on, 20 minutes off.

Melanie: You were going to mention braces, to brace or not to brace. If you're a man in their 40s or 50s and you like to play basketball on a Monday night but your knees bother you, or you like to run marathons, who knows, do you advise braces? Of course we're going to exercise and strengthen those quadriceps, hamstrings, everything you've said. But what about braces? Do you like them?

Dr. Mirsky: I'm not a huge fan of braces. I think there is a role for them. Keep in mind though there are two types of braces. One, the neoprene sleeves and all the elastic support that you see in lots of weekend warriors and lots of evening athletes wearing. Those, although they don't have a real physiological function, they probably help keep the joint feeling warm—might be a little more physiological than anything else. There are the prescribed braces, especially for arthritis, and those are usually braces with hinges, straps that in some way transfer the weight-bearing axis. Those are a little bit cumbersome and are difficult for sports. A sleeve, I recommend for a lot of people as something to try as an adjuvant to other things. But as a primary modality, I don't find a lot of utility in braces.

Melanie: What about some of the other treatments out there? People tried glucosamine and chondroitin, and then I'd like to talk to you about steroid shots and cortisone shots. But first, the alternatives: the creams the lotions, Bengay, glucosamine. What do you think of those?

Dr. Mirsky: Glucosamine and chondroitin are over-the-counter cartilage supplements, those are pills sold at health food stores. They're not FDA approved, there is no real science behind them. Our experience is all anecdotal, but there are lots and lots of anecdotal reports of people who take them and say they help. They are extremely popular worldwide. I do recommend them. I usually have people take a combination glucosamine and chondroitin. I usually recommend they take them for about three months and reevaluate. If they're helping, great, you can continue. If not, might as well stop, and they're probably not going to help. But there's no real science behind them, and the FDA has not latched onto them. It's almost like a vitamin supplement. The steroid injection. That's what you want?

Melanie: Yes.

Dr Mirsky: There are two types of injections that we commonly use in knees: steroids and what are called injectable lubricants or hyaluronic acids. The steroids are good for acute pain, acute exacerbation, usually after an injury. Steroids tend to be short-lived or short-acting, but they're good for an arthritic flare in people with early Osteoarthritis often get flares and aspiration with a steroid injection is very, very useful for that situation. Steroids are not great for chronic long-term management, but for acute exacerbation, I find them very helpful. I find them very helpful after injuries too.

Melanie: And then you mentioned hyaluronic acid.

Dr. Mirsky: Yeah. Those are literally injectable lubricants. They are harvested forms of the fluid that normally nourishes and bathes the joint cartilage. They are given either as one shot, a series of three or a series of five. They can be repeated at six-month intervals, and they are very, very useful. They tend to become less effective over time, perhaps because the arthritic process progresses—not because the medication loses effectiveness—but I think they're very useful. They have minimal side effects; they are expensive. The major side effects are literally local irritation, local reaction, but I find them very, very useful. I usually recommend them after you have therapy, after exercising, activity modification, and [non-steroidal].

Melanie: In the last 20 seconds or so, Dr. Mirsky, wrap up a good healthy knee and prevention treatment for osteoarthritis in the knee.

Dr. Mirsky: Well, I think a good, healthy knee is one that allows you to do what you like to do, to live a healthy, active lifestyle, hopefully without any pain. It should be stable, durable, and functioning. The keys, I think, are healthy, balanced diet; a healthy active lifestyle combining multiple different types of exercises; keeping weight under control; and healthy lifestyle factored with occasional treatment as needed, mostly non-steroidal, exercise, and activity modification. But a healthy knee hopefully should allow that individual to participate in demanding, physically active sports for as long as they wish.

Melanie: Thank you so much, Dr. Eric Mirsky. You've been listening to SMG radio. For more information, you can go to Summitmedicalgroup.com. This is Melanie Cole. Thanks for listening.