Concepts in the Management of Knee, Dr. Jeff Sellman

Regarding knee arthritis which is always a big topic especially in the primary care world primary care sports medicine world and the physical therapy world. Kevin gets out of there.
A couple of things going through here.
We’ve had this talk a couple of times so we try to make it as up and up to date as possible for you and get on the can maybe on the cutting edge things that are going around there but still is a very big industry or a very big moneymaker or a very big money to or depending on how you look at it. Knee OA is osteoarthritis throughout the course of the talk it will be represented as 0A or KOA and while you’re going through here and course the answers will be at the end. But these are the things that certainly can think about why we’re going through the talk is a lot of our patients will ask or will tell you that things may or may not be related to osteoarthritis such as wearing high heels. Of course everyone will tell you that Oh my God my knee hurts I can’t exercise I can’t do anything until I get my knee not hurting anymore.
It is could be a serious health problem. Yes no. Depends. There is certainly a large amount of weight going through each knee joint. As we step and so losing some weight might be very effective. Is nearly a normal consequence of aging and is surgery always required for knee osteoarthritis. All right. Big numbers very large number of people in the country do suffer from knee osteoarthritis making it a very big industry and also a very big moneymaker and also a money depleter. In the in the workforce a lot of people ask for permanent disability or even short term disability associated with the knee osteoarthritis and that also is a very common question in my clinic as well. One of the reasons why it is a very big health concern is actually an indirect correlation between osteoarthritis and actual cardiovascular disease and death because of the lack of walking because as we know walking is likely one of the best exercises we can do to preserve our heart function.
So if we can get people walking we might be able to prevent some unnecessary deaths historically and currently the standard of care for osteoarthritis is to target inflammation and inflammation alone meaning the synovial lining maybe the joint itself and to relieve pain because quite frankly pain is really the only thing the patient is focused on in the knee osteoarthritis setting. However if we were able to jump over to Kevin and change the actual mildew or the environment associated in the joint itself and the bio deep changing the biochemical environment we may actually be able to impact the disease progression itself. However right now although ortho biologics are hot topic at least my clinic a lot of people can’t afford it and it is still not it’s still completely out of pocket. All right. So what are the risk factors many of them are not modifiable but we’re going to focus for the next few slides on the main modifiable one which is the obesity epidemic and increased weight in our population since nineteen seventy five there’s been a triple in the prevalence of obesity in this country leading up to almost 40 percent of the population suffering from obesity that is defined as greater than 30 BMI which is so not as robust marker for measuring obesity.
However we still use it if we were patients out there ask how we go about losing weight or how we go about what is our target weight target hopefully BMI is below 40 but best case scenarios less than 30.
Obesity itself not only changes the biomechanics not only mechanical stress but also has a systemic inflammatory response in the body that could be leading to further destruction in the knee joint itself.
This increase in US zero through the crisis of the knee has led to many surgeons enjoying the outcomes associated with a multitude of knee replacements in the country which will continue to increase as we continue to still not modulate the biochemical markers associated with arthritis. All right. Nearly 40 percent of us in the United States are considered obese and associated with that many millions a year die. So how do we go about combating a diet and exercise back. My knee hurts I cannot exercise if I exercise. That’s the only way I’m going to lose weight. Well I’d like to try to tell patients is that less you know you diet to lose weight. You exercise to get fit. But you can do obviously do a combination of the two. To be the most robust. But there are very few randomized trials out there to compare individually diet individually exercise and with both.
It seems that most people have more of an adherence to a diet as opposed to an exercise program which all your physical therapists out there that’s who we rely on to then start developing somebody some good habits in terms of an exercise program. Many diets out there including ketogenic called the new fads. Most studies are still not supportive of any one kind of course fad diets are just that fad diets. So Mediterranean diet high in olive oil the omega 3s and low in saturated fats seem to still be effective in cardiovascular and also weight loss.
All right so how do we make the diagnosis this is diagnosis we don’t really need anything other than the history and physical examination. So this might be a little redundant to the primary care docs out there but it’s worth saying because I think a lot of times the patient will go to a physician and have knee pain and expect an MRI immediately because that’s what happens on ESPN and they will then get the scope and then they’ll be back maybe tackling somebody the next day. That’s not necessarily the case.
Remember in somebody over the age of 45 who has knee pain that is not associated with a traumatic event progressive in nature plus or minus an effusion or swelling or worse when they first get up in the morning half an hour later they get a lot better and then after they exercise it’s worse again likely a slam dunk diagnosis of knee osteoarthritis don’t really need to go further than that other than start treating. However, come to our clinic, get your x ray. There is one of the good confirmations up there associated with all the different things that we see on an x ray of the decreased base.
This particular is the various compartment and then an actual changing of the bone and then we’ll classify these and then determine what the actual next step is for treatment. So once again MRI is just such a I think in my opinion an overused diagnostic modality in knee osteoarthritis if especially in someone over the age of 45. They come in, once again you diagnose them in your clinic and they haven’t been treated yet. They don’t have an anti inflammatory on board. They haven’t gone to any exercise program because what will likely happen that MRI of that particular knee up there is going to show a terrible medial meniscus if at all. And it will be a complex tear of the medial meniscus of patient reads that report and then they want surgery. Well we also know now that surgeries likely not going to be more effective in terms of an arthroscopic procedure than the actual conservative treatment itself. Once again signs and symptoms of the patient will complain about listen to your patients. I know we all especially at FOI we are going through a new EMR change so you don’t just sit there at the computer typing away look at your patient talk to them get some key things in the history and glean out from them what it is that they their goals are and what it is that they are actually complaining of.
Well it is also interesting is that oftentimes we’ll get an X-ray of a knee and a weight bearing is very important. We’ll get a bilateral weight bearing they’ll complain of left knee pain and actually the right knee looks worse than the left. So the predictability of osteoarthritis is the unpredictability of it. So once again that’s why x rays are not slam dunk. It is the history and the physical examination messy slide. Big old star I do it myself.
And the big thing here is to make sure that we reiterate to our patients that of all stages of osteoarthritis of the knee the main component is a regular exercise program. And a regular exercise program we’ll get to in just a second. Not only keeping the joint moving because motion is lotion, but also we can affect the stability of the knee joint itself. As the cartilage leaves, the instability goes with it or the stability goes with it. But we can absolutely modulate the tendons and muscles around the knee that we can then support a little better moving. Get moving that it’s. Every single day I have this conversation and it’s always the same. Once again you have to kind of break this prejudice that patients have that if they have no pain, they’ll be able to move and they will be able to lose weight. But we need to break the prejudice that you have to get out there and start moving again. You don’t just sit there and say I’m going to have pain just because when I first get up, I mean it has pain 180 minutes a week. that’s what we are suggesting to patients to move, get in the pool, get on a bike, you don’t have to run.
I know a lot of people, either only run just get moving and get that joint moving because motion is lotion. Most cost effective in the treatment of osteoarthritis is a supervised exercise program focused on the hip abductors for other physical therapists. And also the quadriceps and hamstrings all those musculature all the musculature that crosses the joint space itself so that is the first thing that we need to direct people to get them reduce their pain a little bit and then get them moving and then strengthen the muscles around the knee so that we can support that kneecap. the knee better than the other side of it is the people six months later will come back and say I’m in pain well did you go to physical therapy last year.
Yeah. It didn’t work. So you went for how long. Six weeks. Awesome awesome. How were you after physical therapy out of pain.
Completely out of pain and what have you been doing since then. Cheetos and I don’t have a gym.
I’m not going to go out and walk. It’s because they don’t have the motivation. So it’s almost our job to try to motivate them. Get them with a group’s Silver Sneakers something that will motivate them to get back out there because if they continue the home exercise program they’re going to be very well benefited. Another thing to say certainly about diet too I think we as health care providers do a very poor job of having somebody come to the clinic. You have knee arthritis. We haven’t treated you that yet. Your BMI is 35.6. And we tell you’re fat.
Right. Well I just pissed somebody off. You’re fat. Well what are you going to do about it here. I want to give you the tools. There’s so couple medical weight loss programs out there that I’ve been connected with.
Shake it off is one that I’ve been using to really help people get their tools to to eat appropriately better for their own selves and instead of us just telling you you’re fat get out of my clinic. So of course in our medicine pharmacological step up starts as we all know Tylenol instead. And then the Cox 2s depending on their tolerance. But as you also know that anything given orally will always have some sort of side effect that you need to watch out for and says Of course gastric and cardiovascular. There are some studies that may support that close inaccurate. One hundred and fifty milligrams today is superior than the other incense. But in my opinion ibuprofen the tried and true old drug is also very good. I don’t mind using it for 10 to 14 days scheduled and then after that is needed and I won’t discuss opioids for this one.
Once again diet some. Diet is always so controversial it’s so hard to study because we are you know many different things are going in our bodies. Everybody’s a little different we metabolize things differently. I do have a slide for those questions out there from a previous talks about tumor. Some few studies by the Arthritis Foundation and the supplements that may be supportive in an anti-inflammatory overall diet but that’s what diet and the supplements are presumed to attack or presumed to decreases the inflammation overall inflammation in the body. Glucosamine chondroitin is once again inconclusive like Scotty said and the other ones up there just taste good. Glass of wine probably topical as we also do topical as I’d like to try to get people away from orals after they’ve gone through a flare up of arthritis itself. Topical can be an adjunct and or a bridge to either nothing at all or helpful but it’s still some people will get some benefits some people will not. So it’s kind of dependent upon them instead such as Penn said and Voltaire and then local compounding creams which can be very expensive so you must be very careful what you compound it with. So just an anti-inflammatory and an anesthetic such as lidocaine is usually covered by insurance. Capsaicin is hot peppers I don’t like rubbing habaneros on my knees but if you do that might have a local inflammatory response that people use.
All right what about injectables. We’ll just briefly go through these really quickly but we of course start off with corticosteroids is the standard of care a new one out there is an extended relief of triamcinolone which does show to be more effective at decreasing the side effects as regular sitting on. In other words though the loss of cartilage and very similar benefits at about 24 weeks in patients physical supplementation is still inconclusive although we use it and very careful of people do have pain at rest.
At sleeping at all times I tend to tell them I think we need to talk about something else all right biologics we’ll skip. And here is the slide that we were that I do give this list to my patients itself in the amounts that may or may not be beneficial. Glucosamine and conjoined and we do hang our hats on the gate study and they do need to be taken in conjunction not just separately and they are compared to an inset in Celebrex in that particular study but still not very good science. Boswell here is a pine tree bark extract used in Europe and it causes diarrhea which is always fun. Per humans Two thousand milligrams a day is suggested. And then of course the CBD or I’ve talked to a lot of different people there’s so many things out there and certainly I just want to let them all up and take them all one day to see what’s most effective for me.
But I did talk with a local pharmacist at the Davis Island pharmacy and he’s done a really good job of kind of researching everything for us and he suggested a brand called a band. I’m not on board and anything associated with Avandia but he has done his due diligence and that’s what he sells at his pharmacy for CBD oil people at the gym love it either both sub lingual rubbed on or both. All right of all the things we throw at you get moving get rid of the prejudice give them tools to lose weight. That is the only modifiable risk factor associated with me osteoarthritis still a big business and if we can just get Kevin’s stuff to work we’ll be good.
Just kidding. All right. That’s my talk.