Knee - Nonoperative Alternatives

Excerpted from
What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery
By Ronald P. Grelsamer, M.D.

Presumably you've passed the point of trying more nonoperative treatment. In the companion book. What Your Doctor May Not Tell You About Knee Pain And Surgery, I reviewed some of the hanky-panky that goes on in the world of knee pain, especially as it pertains to bogus reports of "torn cartilage" and the resulting unnecessary surgery. But few people undergo unwarranted joint replacement surgery. If your doctor tells you that you need a joint replacement, chances are good that he is correct. The question here is one of timing. Arthritis pain typically comes and goes. The patient visiting the doctor with an arthritic flare-up will agree to just about anything, and occasionally an unscrupulous surgeon will take advantage of that by proposing surgery. You, therefore, want to make sure that you've had repeated and prolonged flare-ups before you agree to joint replacement surgery and will want to have tried a number of the options listed below.

Caveat emptor: Remedies that allegedly require three months of continued use before they can be effective may be taking advantage of the fact that, in that period of time, most arthritic flare-ups will have quieted down on their own.

Rest. This may seem obvious, but people sometimes want to "work through" the pain. An arthritic flare-up demands rest. Gentle exercises can be resumed once the acute pain has abated.

Heat and cold treatment. Although they are opposites, both heat and cold can be soothing. People generally like to be given specific formulas (for example, "Do this for ten minutes, then do that for fifteen minutes"), but when it comes to heat and cold, there is no right or wrong. It's a question of what works best for each individual person. I generally recommend ten minutes of one followed by ten minutes of the other. "Should the heat be moist or dry?" is a frequently asked question. Personally, I have not noted a difference, although individual patients have indicated a preference for one or the other. Some people, for example, feel particularly well in a warm bath. Beware of overdoing it! I've seen people burn themselves with a heating pad. Taking a sedative, imbibing an alcoholic beverage, and falling asleep with an electric heating pad around your knee is not a good idea. When it comes to cold, the key is not to place ice directly on the skin. Believe it or not, you can get frostbite. Place a towel or wrap an elastic bandage between the ice and your skin.

Since the introduction of aspirin, dozens of NSAIDs have appeared on and disappeared from the market. Each one naturally claims to be more powerful and have fewer side effects than the existing ones. These side effects include stomach ulcers, which can hurt and cause serious bleeding, and more insidious damage to various organ systems such as the kidneys. The possibility has even been raised that NSAIDs can harm articular cartilage-the very root of the arthritis problem. I have not personally noted clinical evidence of this, but it is a point worth keeping in mind. The newest class of NSAIDs is the so- called COX-2 inhibitor (valdecoxib [brand name, Bextra], celecoxib [Celebrex], refecoxib [Vioxx], and, in standard doses, meloxican [Mobic]), which are even less likely to cause ulcers than the recent NSAIDs already being touted as mild on the stomach. Note that the COX-2 NSAIDs are not better pain relievers than the other NSAIDs. So if your current NSAID works and you are not at risk for ulcers (speak to your doctor about this), I would not switch. Not to mention that Bextra, Celebrex, and Vioxx are quite expensive.

The following is another common misconception: NSAIDs will reduce swelling. If the knee is swollen due to the irritation of arthritis, then yes, maybe. But if the swelling is the result of an injury, no! You might take ibuprofen, for instance, for the pain of a sprained ankle, but don't expect it to control that goose egg on the outside of your foot!