Knee joint arthrosis / Gonarthrosis: Symptoms and Treatment

Knee arthrosis (gonarthrosis) is a term used to describe all wear-related (degenerative) diseases of the knee joint, which are characterized by increasing destruction of the joint cartilage with the joint structures such as bones, joint capsule, and muscles close to the joint being involved.

Forms of knee joint arthrosis

Three bones, together with a sophisticated capsule and ligament apparatus (collateral and cruciate ligaments), form the framework of the knee joint.

These are:

  • the thigh (femoral rolls or femoral condyles)
  • the head of the tibia (tibial plateau)
  • the kneecap (patella).

In the case of knee arthrosis (gonarthrosis), there is wear and tear of the knee joint. Signs of wear and tear can occur in isolation, or preferably affect the inner or outer part of the knee joint.

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Frequency of knee joint arthrosis

Knee joint arthrosis is a typical adult disease with a high prevalence (27 – 90% depending on the study) among people over 60 years of age. Due to this fact, it is of high socio-medical importance. Knee arthrosis impairs both the ability to work and the personal quality of life.

The female sex is significantly more frequently affected by knee arthrosis.

Causes

Causes for the development of knee joint arthrosis/gonarthrosis:

  • Axial deviations (knock-knees or bow legs)
  • Injuries to the knee joint, e.g., fracture with joint involvement
  • Systemic diseases, e.g., hemophilia
  • Rheumatoid arthritis (rheumatism, chronic polyarthritis)
  • Inflammation of the knee joint by bacteria (bacterial arthritis)
  • Malaligned patella
  • Muscular imbalances caused by, for example, paralysis
  • Osteochondrosis dissecans
  • Osteonecrosis (e.g. M. Ahlbäck)
  • Metabolic diseases, e.g., gout

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Important influencing factors that favor knee joint arthrosis:

  • Overweight
  • Incorrect loading
  • Endocrine factors (e.g., hormones, increased occurrence of arthrosis after menopause)
  • Cruciate ligament rupture

Symptoms of knee joint arthrosis

After lying or sitting for a long time, those affected often complain of a stiffness feeling in the knee joint, combined with a starting pain. The knee joint tends to swell and effusion, which increases the pain even at lower loads.

Irritant attacks, which initially occur rather seldom, are more often noticeable. Also, the knee joint needs more time to return to a non-irritant state. The sensitivity to stress increases more strongly. Climbing stairs and going downstairs and mountains become painful more quickly. The knee joint appears unsteady to the patient, and the irritation symptoms increase.

As the disease progresses, increasingly severe pain forces the patient to stop, for example, when going for a walk. This considerably reduces the walking distance. Due to the pain-related sparing, the muscles of the thigh shrink. Attentive observers have the impression that the stability of the knee joint decreases, especially on uneven ground.

This eventually leads to a situation in which the joint mobility decreases more and more, and even in a state of rest (e.g., during sleep), sometimes severe complaints occur. Changes in the axis of the knee joint, in the sense of bow legs or bow legs can also occur.

Knee arthrosis can lead to fluid retention in the bone due to damage to the joint cartilage. This is usually reflected in the clinical picture of bone edema in the knee.

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Diagnosis

Clinical diagnostics

Palpation:

  • Hyperthermia
  • Effusion, swelling, dancing patella
  • Crepitation, i.e., noticeable rubbing behind the kneecap
  • Patellar mobility
  • Patellar displacement pain (soles – signs)
  • Pressure pain of the patella facets (pressure pain to the right and left of the patella)
  • Pressure pain at the joint gap
  • Functional test and pain test:
  • Assessment of range of motion and movement pain, ligament stability
  • Meniscus sign – to prove damage in the area of the inner or outer meniscus

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Instrumental diagnostics of knee joint arthrosis

In individual cases, useful instrumental investigations:

  • X-ray functional images and individual projections for planning operations and assessing particular forms of arthrosis
  • Sonography (ultrasound): assessment of knee joint effusion, Baker’s cyst
  • Magnetic resonance imaging of the knee: meniscus damage, damage to the cruciate ligament, osteonecrosis
  • Computer tomography: fracture with cartilage level?
  • Skeleton – Scintigraphy: Inflammation?
  • Clinical-chemical laboratory for differential diagnosis = blood examination: signs of inflammation?
  • Puncture with synovia analysis: rheumatism, gout, bacteria?

Magnetic resonance imaging (MRI) is an excellent diagnostic method for determining the extent of knee joint arthrosis.

The MRI shows the soft tissue, especially the cartilage damage in the knee, very well, but the bone can also be assessed. Since arthrosis has many consequences, the MRI can be used very well to assess its course and can reveal consequential damage to the joint apparatus.

The MRI enables a high-resolution image of the cartilaginous parts of the joint – the menisci. These are often affected and worn out in the course of arthrosis of the knee. The extent can be clearly seen on MRI images.

Accompanying injuries to the menisci, such as meniscus tears, can also be detected by MRI of the knee. Knee arthrosis often leads to irregular bony growths in the common area, the so-called osteophytes. MRI can also detect these at an early stage.

MRI of the knee joint can also detect an inflammation of the joint(synovitis/synovitis). A thickened and signal-enhanced joint mucosa is visible. Frequently, a joint effusion develops, which leads to swelling of the knee.

However, the MRI can also detect other pathological changes in the knee joint area, especially cartilage damage. If the adequate blood supply to the bone is no longer guaranteed, so-called osteonecrosis can occur. The bone dies in this area and can cause severe pain. MRI is the diagnostic method of choice to detect such changes at an early stage.

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Treatment of knee joint arthrosis

Exercises

Targeted exercises can make a significant contribution to stabilizing the knee joint muscles and coordination skills as well as relieving the affected joint. Ask your physiotherapist for individual, suitable exercises. In principle, selected exercise units should not be painful and should correspond to the possible range of motion of the knee arthrosis.

Warm-up for about 5-10 minutes before starting the exercises and then carry out the exercises calmly and in a controlled manner. After each exercise, a short stretching phase is recommended to prevent muscle and ligament shortening. To achieve optimal training success, you should complete the exercises two to three times.

Two simple examples can be:

Bridge: Lie on your back and put both legs up. Now lift your pelvis until only your shoulders are in contact with the floor. Hold this position for 30 seconds and then lower your buttocks carefully. As a variation, one leg can be alternately released from the floor and stretched.

Dangling legs: Sit carefully on a tabletop so that your legs hang freely in the air. Then move your legs alternately forwards and backward.

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Drug therapy

The main focus of the drug therapy of knee arthrosis is on pain control. At the beginning of the therapy, drugs such as ibuprofen, paracetamol, Voltaren® (diclofenac), or novamine sulfone (Novalgin®) are suitable. These drugs have an excellent pain-relieving effect, but if they are taken continuously, they can damage the stomach, kidneys, and liver. To prevent inflammation of the mucous membranes of the stomach or gastric bleeding, a stomach acid blocker (proton pump inhibitor, pantoprazole) should be used as a supportive drug therapy, especially if taken over a long period of time.

In cases of advanced knee arthrosis and accompanying severe pain, more potent painkillers may have to be used. Medications from the group of opioids, such as tramadol or tilidine, may be considered.

In the long term, drug therapy of knee arthrosis is only a symptom control and does not eliminate the trigger. Continual and regular use of painkillers, especially ibuprofen, etc., should be avoided due to the many side effects!

Physiotherapy/manual therapy

Physiotherapy and manual therapy are an essential component in the therapy of knee arthrosis. Targeted physiotherapy exercises strengthen the muscular support apparatus, stabilize the knee joint ligaments, and promote the patient’s coordination.

During physiotherapy, patients are gradually introduced to the exercises or devices and ideally learn how to perform them at home. Especially in the case of knee arthrosis, water gymnastics, for example, is ideal because it relieves the joint.

Many patients also suffer from lymph drainage disorders in the affected joint – the knee swells and becomes thick. In manual therapy, special massage and wrapping techniques can provide relief and allow the lymph to drain away.

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Surgery

In the case of knee joint arthrosis, surgery should only be performed on patients in whom all conservative therapeutic measures have been tried over an appropriate period and have not been able to bring about an improvement in symptoms.

In principle, three different surgical procedures can be considered:

Arthroscopy (joint endoscopy, it can be performed open or closed), possibly in combination with a removal of damaged menisci (meniscus tear), cartilage fragments, or the joint mucosa, cartilage smoothing, a so-called bioprosthesis (abrasion chondroplasty) or micro fracturing.

A conversion operation (osteotomy), in which existing knock-knees or bow legs are corrected.

Which technique is chosen depends on various factors, especially age, general condition, individual level of suffering and pain, and the stage of the disease.

During the repositioning operation, the physiological axes in the knee joints are restored in order to prevent the false and excessive loads in the joint caused by the knock-knees or bow legs, thus preventing the progression of arthrosis.

During arthroscopy, parts of cartilage are removed that have become detached in the course of the arthrosis and cause the complaints. The damaged cartilage layer is also strengthened. This measure is usually only carried out on patients in whom the arthrosis is still in a relatively early stage and who still have a layer of cartilage, albeit thin. The advantage of this operation is that it enables the patient to put weight on the knee again relatively painlessly directly after the operation.

However, if the arthrosis is progressing, the cartilage layer is completely lost, at least in places, and there is exposed bone in the joint. Such “bone holes” can be filled up again with fibrous cartilage tissue.

In micro fracturing, tiny holes are made in the bone and then covered with blood containing stem cells. Over time, these form new cartilage tissue that can now cover the joint surfaces and is almost as stable and resilient as the original cartilage.

In abrasion chondroplasty, the entire upper bone layer is removed with a knife-like device. This leads to bleeding into the joint, which ultimately triggers a healing process, which ultimately results in the formation of a cartilage replacement tissue, just like in micro fracturing.

These two techniques are preferable to the endoprosthesis if one has the choice because they regain a higher loading capacity of the knee and represent a repair process of the body’s own, in which nothing is implanted, and therefore there is no danger of rejection reactions or the necessity of a new operation once the prosthesis is worn out.

The knee joint replacement (= endoprosthesis) is therefore mainly carried out on older patients, who, on the one hand usually do not put as much strain on their knee as younger people and on the other hand the limited durability of the artificial joint does not play such a significant role. Even in very severe cases of knee joint arthrosis in younger patients, an endoprosthesis can be inserted after a thorough weighing up of the advantages and disadvantages.

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Alternative therapy of knee joint arthrosis

In addition to operative therapy procedures, it is also possible to treat knee joint arthrosis without surgery. Which therapeutic procedure promises the best therapeutic success in an individual case depends on a number of different factors. Individual factors such as age, profession, sports activities, weight, the extent of the arthrosis, and personal preferences of the patient influence the decision on the treatment method.

In most cases, osteoarthritis of the knee joint is initially treated conservatively. Only if the conservative therapy remains unsuccessful is surgery the last option for treating knee joint arthrosis. It is essential to know that knee joint arthrosis cannot be treated casually. Neither conservative nor surgical procedures can treat the wear and tear disease itself and reverse damage to the joint cartilage. All available treatment options aim to improve the symptoms and slow down the progression of the disease.

The most crucial measure of conservative therapy is the intake of pain and anti-inflammatory drugs (see: Drugs for knee arthrosis). In most cases, so-called NSAIDs are taken, which promise not only symptom relief but also an improvement in the local inflammatory reaction at the knee joint.

Local measures involve injecting anti-inflammatory drugs or hyaluronic acid into the joint. With this measure, an improvement in the symptoms of arthrosis can be achieved for a certain period of time.

Alternative therapy options also include targeted physiotherapy, which can take up different treatment approaches. In addition to professional physiotherapy, which is usually useful in osteoarthritis, heat treatment, acupuncture, or stimulation of the nerve endings in the knee (TENS) can improve the typical symptoms.

Depending on the cause of the arthrosis, orthopedic measures can also help to minimize the progression of the disease and improve the symptoms. Especially the wearing of orthopedic insoles is often recommended in the therapy of arthrosis.

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Ointments for knee arthrosis

There are various approaches to eliminate the symptoms of knee arthrosis and to prevent the disease from progressing. Since knee joint arthrosis is a wear and tear disease of the articular cartilage, there are only limited possibilities of reaching the site of pain. In addition to orally taken drugs or drugs injected into the joint, it is also possible to apply ointments to the knee. As a rule, these are ointments containing pain and anti-inflammatory substances such as Diclofenac. However, it should be noted that the active ingredient contained in the ointments is not able to penetrate to the inside of the joint. Instead, the active ingredient is distributed throughout the body, as it is when taken orally, and can reach the affected joint via the bloodstream.

Progression or healing of knee arthrosis cannot be achieved by applying ointments. If symptoms are present, a doctor should be consulted in any case, who can assess the individual joint damage and make a therapy recommendation.

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Prognosis for knee joint arthrosis

Despite intensive research and development of new therapeutic options, it is not yet possible to cure knee arthrosis. This is due to the fact that once joint cartilage has been destroyed, it cannot grow back and regenerate completely. Even with modern therapy methods, it is usually only possible to improve the symptoms and prevent the disease from progressing.

Although some alternative therapy methods promise a cure for osteoarthritis, these should be viewed very critically, as scientific proof of their effect has not yet been provided. In order to avoid the risk of financial or health damage, it is recommended that a physician provides detailed advice on possible treatment methods.

However, since a progression of the disease can be prevented, a therapy for osteoarthritis is always advisable. An improvement of symptoms can also be achieved in most cases with conventional medical methods.

If knee osteoarthritis is very advanced, implanting a new joint can help to restore the original mobility and freedom from pain. However, since the implantation of an artificial joint is not a measure that is understood as a complete healing of the joint, arthrosis is still considered incurable to this day.

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Jogging with knee arthrosis

The knee joint should not be stressed too much when jogging.

Knee osteoarthritis is a gradually progressive disease of the knee joint. It is often not possible to definitively determine which cause is responsible for the individual development of the disease.

Especially when young people suffer from knee joint arthrosis, however, overloading the joint through sport and a genetic predisposition are suspected to be the triggers for wear and tear. However, sport alone can only be held responsible for osteoarthritis in rare cases. It is even being discussed that regular physical activity is a protective factor against the development of arthrosis. That regular jogging leads to the development of knee joint arthrosis is very unlikely in most cases.

When a knee joint arthrosis is diagnosed, many people wonder whether this represents the end of the sporting activity, especially jogging. In most cases, targeted sports activity combined with appropriate therapy and the performance of specific exercises can help to improve the symptoms of knee joint arthrosis.

When jogging, however, care should be taken to ensure that the knee joint is not subjected to particularly heavy strain. This can be achieved by using special shoes and selecting the jogging route. Sprints and sudden stops should also be avoided. It is also important to remember that if pain occurs, training should be interrupted.

If the load is only possible under painkillers, we advise against a load such as that which occurs when jogging. In these cases, targeted physiotherapy can help to strengthen the muscles of the legs and thus improve the symptoms of knee joint arthrosis.

If the osteoarthritis has been treated by surgery, it is recommended that the joint is first of all strictly protected. In the course of healing, partial or full loading of the knee joint and muscle build-up may be possible and sensible. At what point in time, the resumption of training does not pose a risk to the healing process can be best assessed by the treating surgeon, taking into account the surgical method as well as individual factors.

In general, training should not be resumed without consulting the treating physician if the knee joint arthrosis is present at the same time.

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