Transcription:
Knee Aches and Pains

Melanie Cole, MS (Host): If you suffer from knee pain, you know how debilitating it can be. It can keep you from exercising, it can hurt when you stand up, it can really keep you from taking part in the activities that you enjoy. But if this pain interferes with your daily life, it's really time to see a physician to assess the situation. My guest today is Dr. Mitchell Herrema. He's an orthopedic surgeon with BayCare. Dr. Herrema, thanks for joining us today. Knee pain, so common. Such a big problem in the country today. What are some of the most common causes of knee pain that you see?

Mitchell R. Herrema DO (Guest): Well, first of all I want to thank you for allowing me to come on this program and to talk about my passion, which is orthopedic surgery and specifically hip and knee pain as a hip and knee specialist. The question of what are the major causes of hip and knee pain and arthritis. Number one is going to be a term called osteoarthritis. Osteoarthritis is basically a wear and tear type of process where the joints become arthritic and worn out over time. The other types of arthritis would be rheumatoid arthritis, which I'm sure most people have heard of. It's more of an inflammatory process where not only do the joints become broken down but also the soft tissue in and around the joints become inflamed. Other types of arthritis less common would be traumatic arthritis. If somebody had an injury several years ago and damage to the cartilage, then of course this cartilage is going to break down more quickly over time.

Host: So if someone starts to develop knee pain, if it's acute—if they've injured themselves—that's one thing, but if it's chronic, it starts to get worse over time. How do you diagnose what the cause of the pain is?

Dr. Herrema: So the first thing we do when we see a patient is, of course, we get their history. We talk about different types of activities that cause the pain. Any specific injury maybe they've had recently or in the past. The second thing we do is we get x-rays. We look at these x-rays to determine the amount of space between the joints, whether it's the hip or the knee. When we look at the x-ray we see this space between the two joints. Where the space is, that's where the cartilage is located. When we see the space becoming more narrow, that's how we know that the cartilage has worn away. Then when the bones actually start touching, that's what we call bone on bone arthritis.

Host: So depending on the diagnosis, what's the first line of defense for knee pain? What are some non-surgical treatments that you might try first?

Dr. Herrema: So the first thing most patients do, of course, is called activity modification. They either stop doing the certain activities that cause the pain, they will use sometimes a cane or some sort of assistive device to take some pressure off of the joint. Once the patient gets to the point where they need to see a physician, typically we start with anti-inflammatory medications whether that's over the counter or prescription. The next line would be injections into the joint, anti-inflammatory injections. I also typically prescribe physical therapy. We do know that the stronger our muscles are around the joints, the less pressure we have on those joints and the better they can tolerate certain activities.

Host: So I'd like to touch on the point of injection therapy doctor, but before we do, are you a brace guy? Do you like people to brace? What about ice versus heat if they're feeling that pain?

Dr. Herrema: So regarding braces for the knee, most patients I see don't have what I would consider unstable knees. Most people have very good ligaments stabilizing the knee. So the big, bulky braces sometimes we see people walking around with, they don't necessarily need that. That's probably a little bit of overkill. The braces that I typically recommend patients to try would be a very simple knee sleeve. Maybe something that has a very small hinge but allows the knee to still move and still use the muscles that they have. The number one thing that I think these braces do is they keep the joint warm. Our joints do like to be warm. Arthritis likes to be warm. That's why we tend to hurt more in the winter when it's cooler. Also knee braces give the patient a sense of what we call proprioception where it kind of connects the brain to the knee a little bit better so they can kind of feel where it is in space.

Speaking of heat versus ice, typically we use ice to decrease inflammation. Inflammation would be caused by overactivity. Maybe at the end of the day, if your knee's a little painful or swollen you want to throw some ice on there to decrease that swelling and pain. If joints tend to be a little bit more stiff in the morning, sometimes putting a little bit of heat on the joint can help relax that joint and give a little bit better motion as the day starts.

Host: Thank you for that answer. So touch on injections. We hear about viscosupplementation and cortisone shots and stem cell injections and all of these types of injections. What are they meant to do? Do they work?

Dr. Herrema: So I do think injections work. The question always is going to be how long are these injections going to last for? I'll start with corticosteroid injections. This is probably the number one type of injection most people get in their knees. Specifically in the knees, sometimes the hip. These are very potent anti-inflammatory injections that go right to the source to the pain as opposed to taking oral medications that can have other side effects not only on the kidneys but on your stomach. It can cause ulcers and gastritis. The injections can go right to the source. So most patients will get a number of weeks to months of relief from a corticosteroid injection. As the degradation process of that joint, the arthritis starts to set in a little more, then typically these injections last fewer and fewer number of weeks and months.

Other types of injections would be, like you mentioned, the viscosupplementation. Some of the name brands would be Euflexxa, Supartz, Gelsyn, Synvisc. These types of injections are joint lubrication. They're synthetic joint fluid which is made out of a very similar type of material that our normal healthy joint fluid is made out of. These also do act as a low-dose anti-inflammatory, but they're really made to kind of help lubricate the joint. I would say probably the efficacy of these types of injections are more 50/50 as opposed to the corticosteroids. Those tend to work on everyone. We just don't know how long they're gonna last for.

When you start talking about platelet rich plasma or stem cell injections, probably the biggest downfall to these types of injections is they're not covered by insurance. It's a cash only type of procedure. I've had some patients get very, very good relief from those types of injections. However, stem cells, I personally think, are more for acute pain, tendonitis, trying to get an athlete back to their sports. For severe bone on bone arthritis, I don't typically recommend stem cell as the body needs some good cells to really help recruit new cells for these stem cells. So once these joints become bone on bone then they typically aren't effective.

Host: So then doctor when all else fails and we've tried all of these conservative management therapies to help knee pain, what does the surgical discussion look like? What types of surgery are out there that you can perform to help somebody with their knee pain?

Dr. Herrema: So the two types of surgery typically for knee pain would be arthroscopic surgery and then total joint replacement. Arthroscopic surgery is more for the cartilage type of injuries like a meniscus tear or maybe a loose piece of cartilage that's floating around the knee. Patients that have overall pretty good cartilage in their knee—when I say cartilage, I mean the cartilage that covers the end of the bone—those are the patients that typically do better with arthroscopic surgery. Once you get to the point where you are bone on bone arthritis, arthroscopic surgery is no longer a good option as we're not able to put the cartilage back on the bone through the arthroscopic, or we're not able to really do anything with that joint surface arthroscopically.

When it comes to joint replacement surgery, I tell patients to hold out as long as they can. A lot of patients will come into the office and say, "Do you think I need a knee replacement?" I say the only person that can answer that is you because you're the only one that knows how this knee effects your life on a day to day basis. When the patient gets to the point where they're no longer able to enjoy certain simple activities or walk in the neighborhood and their quality of life is severely diminished, then I say they are a good candidate for joint replacement.

Host: So what does recovery after total knee replacement look like? Just tell us before we wrap up, doctor, how have these replacement surgeries advanced in recent years? Are you using computer navigation and robotic assisted surgery? Tell us what's exciting in the world of joint replacement.

Dr. Herrema: So the thing I always tell patients is we have made great strides in not only our techniques for joint replacement, but also the recovery and the process in the hospital and the early recovery period. I do use both robotic and computer navigation. I think the biggest thing that has helped us with over the last five to ten years and it's become really used commonly is it helps us make the cuts more precise. I think we did a pretty good job before the computer navigation and the robotic assistance, but now we're really able to use this computer navigation in order to know how many millimeters of bone we're cutting, what degrees and angles we're cutting to set these patients up for long-term success.

Host: Then wrap it up for us. What would you like the listeners to take away from this episode as far as knee pain? If they're suffering from it, maybe it's just a little achy in the mornings, but maybe it's really starting to make it difficult for them to stand up from a chair or to go on a long walk. What would you like them to know about when it's time to see somebody and get whatever the situation is looked at?

Dr. Herrema: I think any patient that has joint pain that is starting to affect their life on a daily basis and no longer do certain simple over the counter anti-inflammatory medications allow them to do the things they want to do; I think it's worth them seeing an orthopedic surgeon. The other thing I want patients to know is that joint replacement surgery, although it can seem very scary. It's a major surgery with potential complications, the complication rate for hip and knee replacement are very, very, very low. Now especially with our—like going back to computer navigation and our rapid recovery programs. Getting patients walking the same day of surgery, getting them home either the same day of surgery or after one night in the hospital. Recovery is much quicker, pain control is much better, and complications are much less than they were even five to ten years ago.

Host: Thank you so much Dr. Herrema for joining us today and giving us such great advice from the expert that you are because so many people, as we said, suffer from knee pain. Hearing from an orthopedic surgeon the types of treatment options that are available is so helpful. So thank you, again. That wraps up this episode of BayCare HealthChat. You can head on over to our website at baycare.org for more information and to get connected with one of our providers. If you found this podcast as informative as I did, you must know some people with knee problems. Please share it with them. Share it on social media and don't forget to check out all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole.