What nonoperative approaches for knee OA do you use in recreational vs advanced athletes?
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Similar treatment for all patients
My approach to nonoperative treatment for OA in recreational and advanced athletes is the same, and includes weight loss, physical therapy, intra-articular injection and bracing.
Overweight patients are referred to the weight loss clinic at our institution with the goal of achieving a BMI within the normal range. Physical therapy (PT) is used to achieve full and symmetrical range of motion of the knees, especially full extension, a normal gait pattern, and symmetrical lower extremity muscle strength, flexibility and coordination. Intra-articular steroid injections are used as indicated. Patients with isolated medial or lateral compartment OA may also benefit from unloader brace treatment.Gregory C. Fanelli, MD, is a professor of orthopedic surgery at Geisinger Commonwealth School of Medicine, Geisinger Sports Medicine and Orthopedic Surgery at Geisinger Health System in Danville, Pennsylvania.
Treatment depends on OA factors
Nonoperative approaches for any patient with OA depends upon a stepwise approach, which often depends upon the degree of arthritis, its location, the patient’s range of knee motion and the patient’s tibiofemoral or patellofemoral alignment. One of the important issues to recognize is we need to treat the patient and not the radiographs. This overview refers to patients with more diffuse arthritis changes and not athletes with focal articular cartilage changes that may be candidates for surgical treatment.
One of the key elements in treating these patients is to ensure they are appropriately rehabilitated. If a patient is weaker, especially the quadriceps muscles, then the patient would have less effective absorption of forces with impact. Restoring strength can be key to avoiding joint overload. The next issue is to determine if they need a “boost” to overcome any underlying symptoms, such as an effusion causing mild synovitis or plica irritation, with a corticosteroid or even a biologics injection (usually reserved for cases where a steroid injection did not work initially).
Patients who may have ipsilateral compartment arthritis, such as after a meniscectomy, should have their alignments checked with long leg radiographs. If they are malaligned, then medial or lateral compartment braces can be effective to allow them to return to impact activities or skiing. Similarly, bracing or taping of the arthritic patellofemoral joint, although less effective than treating malalignment of the tibiofemoral joint, can be trialed to try and increase their function.
Probably the most important thing to recognize is that one should not overtreat an athlete with OA initially. Often recreational athletes present with moderate arthritis who may have been functioning well enough with it until recently. Our goal should be to educate them and try to teach them to cross-train to try and allow them to participate in the sports that they love. After the above program fails, then one can search for potential surgical options.
Robert F. LaPrade, MD, PhD, is a complex knee surgeon at Twin Cities Orthopedics in Edina, Minnesota.
Advanced athletes may need more invasive treatment
Nonoperative treatment options are similar for all patients, whether they are recreational or advanced athletes. I think about it as a pyramid. The base, which we build off of, consists of PT to strengthen the surrounding muscles and take load off the joint, activity modification to lessen impact activities using pain/swelling as a guide, and weight loss, if appropriate. The next step up the pyramid is over-the-counter medications, as needed, for pain (for example, acetaminophen or NSAIDs). The following step is injections (cortisone or lubricating gel injections). In certain situations where the arthritis and pain are in one specific part of the knee, I also consider adding an unloader brace with activity. With recreational athletes, we generally start at the base of the pyramid and work up, if symptoms are not controlled with the previous level of treatment. Advanced athletes may not be able to modify their activities as easily or allow the time for PT to take effect, so we may need to start further up the pyramid with more invasive options. Ultimately, every patient works their way through the pyramid differently and we adjust our approach for each individual taking into account their symptoms and activities.
David A. Wang, MD, is a sports medicine physician at Hospital for Special Surgery in New York.