Osteoarthritis of the knee

Osteoarthritis of the knee typically starts with knee pain that only occurs when you put strain on the joint. If the osteoarthritis gets worse over time, this pain gets stronger and more frequent. You may even feel it when you rest the joint or at night, and it may stop you from sleeping properly. You might have other symptoms too, like joint stiffness. Some people’s joints are especially painful in the evenings or mornings.

Depending on the part of the knee that is affected, the left or right side of the knee may hurt more. If the area under the kneecap is affected, it mainly hurts when you do things like getting out of a chair and climbing stairs.

In severe osteoarthritis, the joint also hurts when at rest. Then the pain is often duller and may be very intense at times, lead to exhaustion and really limit what you can do in everyday life.

The knee joint can also become stiffer and more tender to the touch. Moving it less weakens the muscles and ligaments around it, making your knee feel unstable.

Some people have acute flare-ups of osteoarthritis in their knee. Then the pain suddenly gets worse and feels more like a stabbing, throbbing or burning sensation. The knee might become swollen, stiff and warm. This is sometimes referred to as an active phase of the disease. The symptoms that occur during flare-ups usually go away again within a few days. Flare-ups often come without any warning. This can make it particularly hard to cope with them.

Osteoarthritis of the knee can develop in three areas:

• On the side of the knee joint facing the other knee (medial)
• On the side of the knee joint facing away from the other knee (lateral)
• Under the kneecap (patellofemoral)

The knee joint connects the thigh bone (femur), shinbone (tibia), calf bone (fibula), and kneecap (patella) with each other. The ends of the bones and the inner side of the kneecap are covered with cartilage. Healthy cartilage has a smooth gliding surface that allows low-friction movement in the joint. Osteoarthritis develops if the cartilage softens and becomes cracked and thinner. Cartilage damage can be caused by various things, including the following:

• Knee injuries, for instance due to meniscus damage, a torn anterior cruciate ligament, dislocation of the kneecap, or a bone fracture near the knee joint.
• Being very overweight: People with a body mass index ( BMI) over 30 have a higher risk of osteoarthritis. The extra weight puts more strain on the knee and can also make joint inflammation worse.
• Your anatomy: Having legs of different lengths or knee problems (knock knees or bow legs), for example.

People often refer to osteoarthritis as "wear and tear" of the joints. This is misleading because it suggests that that osteoarthritis can't be stopped and that the joint is worn down through normal use. But that's not the case! On the contrary: the tissue in our joints is constantly being broken down and replaced. The joint needs to be moved in order to help it make the new tissue. This makes sure that the knee gets enough blood. Movement is also important for the cartilage. Like a sponge, cartilage releases waste products when squeezed and absorbs nutrients from the joint fluid when released again. So specific types of exercise and sports, like brisk walking or cycling, are good for your cartilage and joints even if you have osteoarthritis.

In Germany, an estimated 4% of all adults have osteoarthritis of the knee. It is more common in people over the age of 40.

Having osteoarthritis doesn’t necessarily mean that the knee will eventually become so damaged that you’ll need a joint replacement. Many people manage their daily lives well despite the symptoms.

It is hard to accurately predict how osteoarthritis will continue to develop over time. A lot of people only have mild symptoms for many years, and in other people they progress more quickly. Sometimes the symptoms even improve over time.

A review of studies involving more than 7,000 participants showed the following over five to eight years:

• The pain stayed about the same in around 85% of the participants.
• It got worse in about 7% of the participants.
• And it got better in about 8% of the participants.

Even though osteoarthritis of the knee usually progresses gradually and is often stable for years, it can keep getting worse for a few days or weeks at a time.

About 40% of people with osteoarthritis have acute flare-ups, especially if they have already had the disease for a long time. Most of them have about one flare-up per month, but the frequency varies a lot.

How much osteoarthritis affects you depends on factors other than the condition of your knee joint. These include your individual attitude, your social and work life, your lifestyle, and also emotional aspects like fears, worries and stress. They can all affect how the symptoms feel, how severe they are, and how you cope with them.

Advanced osteoarthritis of the knee can cause changes in the knee joint. After cartilage is lost, the bone under the cartilage thickens and hardens, and bone spurs called osteophytes can form on the edges of the bone. They can limit the joint’s range of motion and irritate tendons and ligaments, causing pain.

In very advanced osteoarthritis, parts of the cartilage may be completely gone. Then the bones of the joint rub directly against each other.

Osteoarthritis of the knee can also lead to meniscus (cartilage disk) damage, weaker muscles, and loose ligaments. There might be too much fluid in or around the joint as well, which can be painful.

A doctor can usually diagnose osteoarthritis of the knee based on the typical symptoms. They will ask how long you have had the pain, what it feels like, and whether there are other symptoms such as stiffness in the knee in the morning. Then the doctor will check how much you can move your knee, feel the knee and the joint space, and examine the muscles.

Imaging techniques such as x-ray, ultrasound or MRI ( magnetic resonance imaging) scans can’t tell us much about the symptoms of osteoarthritis. Some people have big changes in their joint but hardly any symptoms, while others have severe symptoms but a healthy-looking joint. Studies also show that people who have no symptoms often have visible changes in their knee joint:

• About 20% of people over the age of 40 have a torn or damaged meniscus that is visible in MRI scans.
• Around 40% have changes in their cartilage.
• And about 40% have osteophytes or changes in their bones.

If these types of changes are wrongly thought to be causing the symptoms, it may result in unnecessary anxiety and ineffective surgery. The treatment of the symptoms should be based on your symptoms and individual situation, and not what can be seen in scans.

Imaging scans or blood tests can be useful if your doctor thinks that you might have another disease like rheumatoid arthritis or gout, or to see whether a bone has been broken after a fall or accident. Knee scans are also done before implanting an artificial joint (joint replacement), in order to plan the surgery.

There are various treatment options for osteoarthritis of the knee: The most suitable ones will depend on things like how advanced the disease is, whether you have any other medical conditions, and what you expect from the treatment.

Even if you have osteoarthritis, staying as active as possible is good for your joints. Many studies show that regularly doing strength and mobility exercises can relieve pain and improve joint function. Yoga and tai chi are options as well. If you’re overweight, losing weight can reduce stress on the joints. Studies have shown that weight loss of more than 5% can improve your mobility and relieve joint pain somewhat. For instance, that would mean losing at least 5 kilograms (11 pounds) if you weigh 100 kilograms (220 pounds).

You can also try out well-fitting shoes with thick and sturdy soles that support the arch of your foot. There should be plenty of room for your toes. Shoes with thin, flexible soles – like “barefoot” shoes – and shoes with high heels are less suitable.

There are also many treatment approaches for osteoarthritis of the knee:

• Insoles, orthotics, and special “unloading” shoes are low-risk options that can be tried out. There's a lack of good research on the effects of insoles and orthotics, though. One good-quality study showed that wearing unloading shoes (designed to reduce pressure on the knee) helped. But they weren’t any better than normal, well-fitting, impact-absorbing shoes.
• Applying creams or gels containing anti-inflammatory painkillers such as diclofenac to the joint can relieve osteoarthritis pain in some people. They are a simple treatment option with a low risk of side effects.
• Oral anti-inflammatory painkillers that are swallowed (like diclofenac, ibuprofen, and etoricoxib) have also been proven to relieve osteoarthritis pain. Acetaminophen (paracetamol) doesn't help in osteoarthritis of the knee. Opioids often aren’t any more effective than anti-inflammatory painkillers, but they have more side effects and can lead to dependency.
• Acupuncture: Studies suggest that acupuncture can relieve osteoarthritis of the knee – but no better than fake (placebo) acupuncture does, where needles are inserted only superficially or in the “wrong” place. In Germany, statutory health insurers cover the costs of acupuncture for osteoarthritis of the knee.
• Injections into the joint: Steroid injections can relieve the symptoms for up to eight weeks, but may damage the cartilage if used repeatedly for a long time. Injections of blood taken from your own body (platelet-rich plasma) or stem cells have not been shown to work. There is also no proof that hyaluronic acid injections help. On the contrary: They may even be harmful.
• In advanced osteoarthritis of the knee, joint replacement surgery may be considered. An artificial knee joint can considerably relieve the pain of advanced osteoarthritis in most people. After surgery, it’s important to have active rehabilitation treatment – and to be patient because it takes time to get used to the new knee.
• A treatment called corrective osteotomy is sometimes considered as an alternative to joint replacement. It involves the correction of misalignments that put too much strain on one part of the knee and are responsible for the osteoarthritis.

There are also many other products and therapies for osteoarthritis of the knee that don’t have a proven benefit. These include:

• Duloxetine
• Plant-based products such as devil’s claw or frankincense
• Dietary supplements containing chondroitin or glucosamine
• Foods or food extracts, for example based on soy, avocado or turmeric
• Ultrasound treatments
• Transcutaneous electrical nerve stimulation (TENS)
• Leech therapy
• Acupuncture
• Psychological treatments
• Whole-body vibration
• A special kind of electrotherapy (“high tone power therapy”)
• Magnetic field therapy
• Microwave therapy
• X-ray therapy (orthovoltage therapy)
• Radiosynoviorthesis (RSO)
• Endoscopic lavage (washing) of the knee and smoothing of the cartilage (arthroscopy).

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German health care system and find a suitable doctor. You can use this list of questions to prepare for your appointment.