Anatomy & Background
As the largest joint in the body, the knee is designed for both mobility and stability. It is a weight-bearing joint comprised of three joints, as well as four bones. The osseous joints in the knee include the tibio-femoral joint, patella-femoral joint and tibio-fibular joint.
Bones and Joints
To understand the joint complex in the knee, each joint and the bones that are connected within joints, must be considered individually. These include:
- Tibio-femoral joint – This is a hinge joint situated between the tibia (the large bone in the lower leg) and the femur (the large bone in the upper leg and the largest bone in the body). There is a medial (closer to the middle) and lateral (closer to the outside) section of the joint.
- Patella-femoral joint – This joint is situated between the patella (“knee cap”) and the femur in the upper leg. The patella-femoral joint allows the patella to glide along a groove in the anterior distal section of the femur.
- Tibio-fibular joint – This joint is situated between two bones from the lower leg – the tibia (larger bone) and the fibula (smaller bone) – where they meet at the knee.
Unlike other forms of arthritis, rheumatoid arthritis is a systemic autoimmune disease that is not caused by common wear-and-tear on the joint. This condition usually affects joints symmetrically (for example, both knees, both wrists, both shoulders). Rheumatoid arthritis causes degeneration of the articular or joint cartilage. It can also affect the tissue that surrounds and lubricates the joint. If the joint surfaces and cartilage are not lubricated they can start to rub, causing wear.
Rheumatoid arthritis can affect other parts of the body including organs like the heart and lungs, and can even cause fatigue. The cause of Rheumatoid arthritis is not fully known. It is considered an autoimmune disease, where the cells of the body attack themselves. Although it is a chronic condition, individuals can have periods of little to no symptoms mixed with acute or symptomatic periods. There can be a genetic component to this disease.
Symptoms of Rheumatoid Arthritis
- Pain is present over the knee joint often affecting both right and left.
- Swelling and inflammation of the joint.
- The joint feels hot or warm to the touch.
- Stiffness and loss of motion of the knee (or other joint) when bending and/or straightening the joint.
- Weakness, which may be manifested as difficulty walking, getting up from a sitting position, kneeling, squatting or climbing stairs.
- Fatigue or tiring easily when performing normal daily activities.
Things to Consider when you have Rheumatoid Arthritis
The ideal treatment involves a combination of medication, rest, joint range of motion and strengthening exercises, joint protection strategies, such as bracing and splinting, and patient education. Restoring range of motion and strength is important to maintaining function. Protecting the joint through education about movement, and bracing and splinting when necessary can help reduce further joint damage. Treatment is customized depending on the individual’s age, level of function, acute versus chronic flare ups, pain level and general health.
- Rest: avoid the activities that produce the pain. Avoid jumping, running, going up and down stairs, kneeling, squatting and walking for extended periods of time.
- Ice or moist heat: apply ice to the joint or area of pain or inflammation. It is one of the fastest ways to reduce swelling, pain and inflammation. Individuals with Rheumatoid arthritis may not tolerate ice well. The application of moist heat may be helpful with stiff joints. The application of ice or heat should be done at intervals for about twenty minutes at a time. Do not apply directly to the skin.
- Compression: when using ice, apply light compression. This is especially helpful if swelling is present.
- Elevation: elevate the area to help reduce swelling.
- Movement: keep your joints moving whenever possible. When pain occurs, the tendency of most individuals is to not move, but this will only result in further loss of motion and lead to increased pain and loss of function.
Managing Rheumatoid Arthritis with Medicine
Early aggressive medical care is recommended for individuals with Rheumatoid Arthritis. Interventions may include the following:
- The use of DMARD (disease modifying anti-rheumatic drugs).
- The use of NSAIDS (non-steroidal anti-inflammatory drugs)
- When indicated, steroids in low doses will be prescribed to reduce joint inflammation.
- Physical and Occupational Therapy to develop a stretching and strengthening program.
- Bracing and splinting to protect and rest the involved joints.
- Surgery may be needed in severe cases. An arthroscopic procedure to remove an inflamed synovial lining is one surgical option. In the case of severe joint and cartilage degeneration a total knee replacement is the preferred procedure.
Managing Your Pain
If you are experiencing persistent or chronic knee arthritis, pain management intervention can assist in managing both acute and chronic pain. Avoiding the activities that cause or exacerbate pain is the first line of treatment, as is using at-home methods such as RICE (rest-ice-compression-elevation) and temporary immobilization techniques such as bracing, taping, strapping or splinting.
Additional pain management interventions may include:
- Medication – The use of non-steroidal anti-inflammatory drugs (NSAIDs) can reduce pain, swelling and inflammation. If knee arthritis is caused by rheumatoid arthritis, the use of disease modifying anti-rheumatic drugs (DMARDs) may improve the your overall condition.
- Steroid injections – Low doses of steroids, injected into the knee joint, can reduce inflammation.
- Synvisc or Suparz injections -– Joint injections of hyaluronic acid preparations like Synvisc or Suparz help to facilitate the repair and regeneration of cartilage in the joint.
- Physical therapy – Following a thorough analysis of the affected joint, including assessing the level of inflammation, flexibility, strength, balance and gait, a series of stretching and strengthening exercises may be initiated to improve strength and flexibility of the knee joint. Changes to gait can also reduce stress on the joint, and other techniques including manual therapy, ultrasound, electrical stimulation, cold therapy and ice may be used to reduce pain and inflammation.
- Surgery – Surgery is a last-resort method for managing chronic and severe pain resulting from knee arthritis. In some cases, arthroscopic surgery can be performed to debride (clean out) the affected joint surfaces and synovial lining, with the goal of reducing inflammation and swelling. If severe joint degeneration has occurred and other methods of pain management have been unsuccessful, a partial or total knee replacement may be recommended.
The prognosis for individuals affected by arthritis of the knee will depend on a number of factors, including the type of arthritis that is causing symptoms (osteoarthritis, rheumatoid arthritis, traumatic arthritis), the severity of the joint damage and cartilage degeneration, the strength and flexibility of the joint, and other factors such as the age, weight, level of physical fitness and overall health of the individual. The timing and type of treatment utilized will also affect arthritis outcomes.
It is best to discuss outcomes and prognosis based on the level of severity of the condition with your doctor. This can be the most important factor in affecting the outcome of treatment.
- Mild Cases – Patients experiencing mild forms of arthritis in the knee, associated with minimal degeneration and damage, generally respond well to short-term, conservative treatment when flare-ups occur. Using the RICE method (rest-ice-compression-elevation) at the onset of pain, coupled with non-steroidal anti-inflammatory medication (NSAIDs) if needed, and followed by a program of mild stretching and strengthening exercises is generally all that is required to experience improvement. Most patients can expect to see diminished or eliminated pain and improved function within 4 – 6 weeks.
- Moderate Cases – Patients that experience moderate degeneration due to arthritis may need more than just rest, medication and exercises to see an improvement in symptoms. If there is increased degeneration or damage due to more serious or chronic arthritis, the individual may have more pain, weakness, and loss of mobility and functioning. Pain management techniques such as steroid injections or injections of hyaluronic acid preparations can help to reduce inflammation and repair or regenerate cartilage in the knee joint. Arthroscopic surgery may be required to debride (clean out) the knee joint. Following this procedure, recovery can be expected to take 6 – 9 weeks, and the surgery should be followed by an exercise or physical therapy regimen aimed at restoring strength, range of motion and function.
- Severe Cases – For patients that experience severe joint damage and degeneration due to knee arthritis, marked by significant pain, swelling and stiffness, as well as loss of strength, motion and function, traditional treatments that help those with mild to moderate knee arthritis may not be sufficient. Conservative treatments are generally tried first before attempting a more invasive technique, but if the cartilage is severely eroded and there is bone-on-bone contact in the joint, a partial or total knee replacement is typically the treatment of choice. Joint replacement surgery is usually followed by 3 – 4 months of rehabilitation (physical therapy), although it can take up to a full year for recovery to be complete. Most patients that undergo joint replacement surgery see dramatic improvements in knee function, reduction in pain and the opportunity to return to a better quality of life. However, the artificial joint will still feel and operate differently than a natural joint and may result in some limitations.