Knee Osteoarthritis (Gonarthrosis): Therapy

General measures

• Activated osteoarthritis (osteoarthritis with signs of inflammation):
  • Systemic or topical nonsteroidal anti-inflammatory drugs (NSAIDs) (see “Drug therapy” below).
  • Immobilization of the joint
  • Local cold application
  • Intra-articular (“into the joint cavity”) glucocorticoids.
• Nicotine restriction (refraining from tobacco use).
• Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day); ≥ 20 glasses of beer/week lead to a significant increase in coxarthrosis (hip osteoarthritis) and gonarthrosis (knee osteoarthritis); individuals who drank 4 to 6 glasses of wine per week had a lower risk of gonarthrosis
• Aim for normal weight! Determine BMI (body mass index) or body composition using electrical impedance analysis and, if necessary, participate in a medically supervised weight loss program or program for the underweight.
  • Consistent weight loss of overweight or obese individuals (BMI ≥ 25 or 30 kg/m2) can stop incipient gonarthrosis (confirmed by MRI examination).
  • Weight loss in overweight men and women (body mass index 27 to 41) of more than 18 months with incipient gonarthrosis, ie, with moderate-grade changes in the joint (Kellgren and Lawrence score of 2 to 3), has a pain-relieving effect that increases with the extent of weight loss.
• Include physical activity (e.g., walking; tai chi) for all patients with coxarthrosis (hip osteoarthritis) or gonarthrosis (knee osteoarthritis) with mild to moderate symptoms to minimize pain and improve mobility; an additional exercise program may reduce the need for arthroplasty in patients with coxarthrosis by 44% for the previously named group
• An upright posture – while sitting and standing – relieves stress on the joints.
• Avoidance of:
  • Excessive load due to increased body weight mainly affects the medial femorotibial joint (FTG; two partial joints of the knee joint; in it, the condyles (articular cartilages) of the femur and tibia articulate with each other), and to a lesser extent on the lateral femoropatellar joint (FPG; formed by the kneecap as well as the lower portion of the femur); evidence was obtained by magnetic resonance imaging.
  • Overloading of the joints, e.g., by competitive and high-performance sports or long-lasting heavy physical loads, e.g., in the profession (construction workers, especially floor layers).
  • Lack of physical activity, since the cartilage gets its micronutrients from the synovial fluid, it is dependent on the joint being moved; lack of movement is dangerous even at low BMI.
  • Incorrect footwear – A resulting foot malposition can lead to wear and tear of the joint cartilage. Frequent wearing of high heels is particularly harmful.

  Conclusion: both overload and too little load can damage the cartilage.

Conventional non-surgical therapy methods

• Therapy with chondroprotectants (cartilage protection preparations) – supplements (vital substances) containing glucosamine and chondroitin sulfate are considered suitable chondroprotectants.

Medical aids

Orthopedic aids are of importance for a mechanical load distribution. There are the following options:

• Footwear with good cushioning! (Buffer heels, shoe elevation if necessary)In a randomized study with patients who had gonarthrosis, the comparison of orthopedic shoes with normal new shoes as a therapeutic measure showed no significant differences for pain reduction and function, but both groups felt significant improvements in terms of pain as well as function.
• Lateral insoles in shoes (lateral wedge) in patients with medial knee osteoarthritisLoad reduction:
  • Early phase of stepping: barefoot walking 7.6%; lateral insoles reduced load by 5.9% (lateral wedge) and 5.6% (lateral wedge with medial support), respectively
  • Late-phase stride: barefoot walking did not lower knee load; lateral insoles lowered knee load
• Walking stick
• Orthosis – orthopedic device for relief and immobilization of the affected joints.

Nutritional medicine

• Nutritional counseling based on nutritional analysis
• Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
  • Daily total of 5 servings of fresh vegetables and fruits (≥ 400 g; 3 servings of vegetables and 2 servings of fruits).
  • Once or twice a week fresh sea fish, i.e. fatty marine fish (omega-3 fatty acids) such as salmon, herring, mackerel.
  • High-fiber diet (whole grains, vegetables).
• Selection of appropriate food based on the nutritional analysis
• See also under “Therapy with micronutrients (vital substances)” – Taking a suitable dietary supplement.
• Detailed information on nutritional medicine you will receive from us.

Sports Medicine

• Regular exercise ensures that joint cartilage is well supplied with synovial fluid. In addition, physical activity helps build bone mass.
  • Not only swimming and cycling, but also jogging, aerobics or tennis, do not cause the knee joint to wear out faster as a result. In one study, practicing the aforementioned sports – adjusted for age, gender and BMI – did not lead to significant osteoarthritis development, either in the overall evaluation or in the low- to moderate-intensity groups, nor in the highly active.
• Endurance training (cardio training) and strength training (muscle training) and flexibility training.
• Strengthening the muscles surrounding the joint can relieve arthritis symptoms.
• Cycling, swimming, aqua gymnastics and Nordic walking are joint-friendly sports.
• Sports with rapid changes of direction and high pressure loads such as volleyball, handball and badminton are not recommended.
• Sports exercises and muscle building programs (individualized strength training).
• In mild gonarthrosis, an aerobic exercise program with small jumps in postmenopausal women resulted in improved cartilage structure detectable by magnetic resonance imaging (MRI). Significant improvements in knee injury and osteoarthritis outcome score (KOOS) parameters of pain, symptoms and function, and quality of life could not be demonstrated.
• Runners and ex-runners versus never runners: less frequent gonalgia (knee pain), radiographic signs of osteoarthritis, and symptomatic osteoarthritis. Risk reduction: 17-29%.
• Caution: monotonous movements and overload (sports, occupation) can damage articular cartilage.
• Preparation of a fitness or training plan with suitable sports disciplines based on a medical check (health check or athlete check).
• Detailed information on sports medicine you will receive from us.

Physical therapy (including physiotherapy)

Physical therapy can help alleviate symptoms. It offers a wide range of treatment methods that support the therapy of osteoarthritis:

• Balneotherapy (bath therapy).
  • With warm mineral salt baths
  • Serial healing peat baths (“moor baths”)
• Exercise therapy – cycling, swimming, or walking can help slow the degenerative process and improve pain, functionality, and quality of life
• Occupational therapy
• Physiotherapy – In a randomized trial, the symptoms of gonarthrosis were relieved as well as by a corticosteroid injection (triamcinolone) in the first weeks: after the first 4 weeks, the “Western Ontario and McMaster Universities Osteoarthritis Index” (WOMAC) had dropped to 48.2 points in the physiotherapy group and to 55.4 points after the corticosteroid injection (the difference was not significant). Secondary endpoints also showed advantages for physical therapy: in the “Alternate Step Test,” patients were 1.0 seconds (0.3 to 1.6 sec.) faster; in the “Up and Go” test, the advantage was 0.9 seconds (0.3 to 1.5.).
• Thermotherapy, this consists of heat and cold therapy (cryotherapy):
  • Heat therapy in the form of balneotherapy (warm water baths with mineral salts dissolved in it) or electrothermotherapy (e.g. diathermy) has analgesic (pain-relieving) effects and improves walking distance and health-related quality of life.
  • Cryotherapy is used only in active, inflammatory osteoarthritis.
• Ultrasound – Pain reduction by long-term treatment with low-energy ultrasound (132 mW/cm2; total energy over four hours of application was 18,720 joules) was confirmed; treatment duration: during the day for four hours and seven days a week for a period of six weeks.

Complementary treatment methods

• Acupuncture for analgesia (pain relief) in gonarthrosis (osteoarthritis of the knee joint); significant improvement in health-related quality of life compared with physiotherapy alone.
• Leech therapy
• Electrostimulation for analgesia in gonarthrosis:
  • Interferential current therapy (IFT) (in a meta-analysis, the only procedure most likely to be used for pain management).
  • Whole body vibration (WBV) – Has been shown to reduce pain and improve functional status in gonarthrosis patients.
  • Neuromuscular electrical stimulation (NMES).
  • Noninvasive interactive neurostimulation (NIN).
  • Pulsed electromagnetic field therapy (PEMF).
  • Transcutaneous electrical nerve stimulation with radiofrequency pulses (h-TENS).
  • Transcutaneous electrical nerve stimulation with low-frequency pulses (l-TENS).
• High-Intensity Ultrasound (HIU) – The procedure is used for localized, noninvasive delivery of therapeutic compounds (pharmaceuticals) by ultrasound to articular cartilage and subchondral bone. [The procedure is still in testing.]
• Magnetic resonance therapy (MRI) (Synonyms: MBST nuclear magnetic resonance therapy, nuclear magnetic resonance therapy, multibiosignal therapy, multi-biosignal therapy, MBST nuclear spin) – treatment method in which the magnetic resonance imaging (MRI; magnetic resonance imaging; short: nuclear spin) known from diagnostics is used therapeutically. The procedure aims at reactivating metabolic processes in the cells, thus enabling the regeneration of defective cartilage and bone tissue.
• Cabbage poultice, (poultice made from white cabbage leaves) – In a small study, cabbage poultice performed better than “previous” therapy in terms of pain, joint function and quality of life after a four-week treatment period. However, there was no benefit compared to pain gel application (1-4 g of pain gel containing diclofenac; 10 mg of diclofenac per g of gel).
• Pulsed Magnetic Field Therapy (PMT) – physical procedure that usually uses pulsed electromagnetic fields (PEMF) to improve microcirculation and stimulate and regulate cellular and energy balance.
• Yoga – for pain in knee joint osteoarthritis.