Treatment of osteoarthritis of the knee joints, treatment of gonarthrosis- to put it mildly, not an easy task. Before you begin your difficult battle with this disease, be sure to find a good doctor, be examined by him and make a treatment plan with him.
Never try to diagnose yourself!
The fact is that arthritis-like joint injuries occur in many other diseases, and poorly informed people often make mistakes in determining the diagnosis. It is better not to save time and money on a medical care because a mistake can cost you much more in all respects.
But this does not mean that you are obliged to blindly believe in any doctor and should not delve into the essence of his recommendations and understand the mechanism of action of the drugs prescribed to you. The patient must understand the importance of medical prescriptions and imagine why certain medical procedures are performed.
So in the therapeutic treatment of gonarthrosis, it is important to combine a number of therapeutic measures in such a way that several problems are solved at once:
- eliminate pain
- improve the nutrition of articular cartilage and speed up its recovery
- activate blood circulation in the affected joint area
- reduce the pressure on the damaged joint areas in the bones and increase the distance between them
- strengthen the muscles around the diseased joint
- increase joint mobility.
Below we look at how a particular treatment method can help you achieve your goals:
1. Non-steroidal anti-inflammatory drugs:
Non-steroidal anti-inflammatory drugs - NSAIDs: diclofenac, piroxicam, ketoprofen, indomethacin, butadione, meloxicam, celebrex, nimulide and their derivatives.
With osteoarthritis, non-steroids are used, ie. non-hormonal, anti-inflammatory drugs traditionally to eliminate pain and inflammation in the joint, as it is impossible to start normal treatment due to severe pain. Only after removing acute pain with anti-inflammatory drugs, you can subsequently, for example, proceed to massage, gymnastics and the physiotherapy procedures that would be intolerable due to pain.
However, it is undesirable to use drugs from this group for a long time, as they are able to "mask" the manifestations of the disease.
After all, when the pain subsides, a misleading impression is created that a cure has begun. Osteoarthritis, meanwhile, continues to develop: NSAIDs only eliminate individual symptoms of the disease, but do not cure it.
In addition, data indicating the detrimental effect of long-term use of non-steroidal anti-inflammatory drugs on the synthesis of proteoglycans have been obtained in recent years. Proteoglycan molecules are responsible for the introduction of water into cartilage, and violation of their function leads to dehydration of cartilage tissue. As a result, cartilage already affected by osteoarthritis begins to deteriorate even faster. Thus, the pills that a patient takes to relieve joint pain can accelerate the destruction of the joint.
In addition, keep in mind that when using non-steroidal anti-inflammatory drugs, they all have serious contraindications and can cause significant side effects with long-term use.
Chondroprotectors - glucosamine and chondroitin sulphate:
Chondroprotectors - glucosamine and chondroitin sulphate - are substances that nourish cartilage tissue and restore the structure of damaged articular cartilage.
Chondroprotectants are the most useful group of drugs for the treatment of osteoarthritis.
Unlike non-steroidal anti-inflammatory drugs (NSAIDs), chondroprotectors do not so much eliminate the symptoms of osteoarthritis as they affect the "basis" of the disease: the use of glucosamine and chondroitin sulfate helps restore the cartilage surfaces of the hip joint and normalize its joint fluid production. "lubricating" properties.
Such a complex effect of chondroprotectors on the joint makes them indispensable in the treatment of the initial stage of osteoarthritis. However, there is no need to exaggerate the capacity of these drugs.
Chondroprotectors are not very effective in the third stage of arthrosis when cartilage is almost destroyed. After all, it is impossible to grow new cartilage tissue or bring the deformed knuckles back to their former shape using glucosamine and chondroitin sulfate.
And in the first or second stage of gonarthrosis, chondrocytes protect very slowly and do not immediately improve the patient's condition. To achieve a real result, it is necessary to undergo at least 2-3 courses of treatment with these drugs, which usually takes from six months to a year and a half.
3. Healing ointments and creams:
Healing ointments and creams can in no way cure osteoarthritis of the knee joints (although their ads claim otherwise). Yet they can relieve the patient's condition and reduce pain in the sore knee. And in this sense, ointments are sometimes very useful.
So in case of osteoarthritis of the bone joint that continues without synovitis, I recommend that my patients heat ointments to improve blood circulation in the joint.
To do this, use paprika extract, etc. The listed ointments usually make the patient feel comfortable warmth and comfort. They rarely cause any side effects.
Ointments based on non-steroidal anti-inflammatory drugs are used in cases where the course of gonarthrosis is exacerbated by synovitis. Unfortunately, they do not work as effectively as we would like - after all, the skin does not allow more than 5-7% of the active substance to pass through, and this is clearly not enough for the development of a full-fledged anti-inflammatory effect.
4. Means for compaction:
Compresses have a slightly greater therapeutic effect compared to ointments.
Of the topical drugs used in our time, three drugs deserve the most attention in my opinion: Dimexid, Bischofit and Medicinal Bile.
Dimexide- a chemical substance, a liquid with colorless crystals, has a good anti-inflammatory and analgesic effect. At the same time, unlike many other drugs for external use, Dimexide is actually able to penetrate skin barriers. Dimexid applied to the skin is actually absorbed by the body and works inside it, reducing inflammation in the focus of the disease. In addition, Dimexide has a resorbing property and improves the metabolism in the application area, making it most useful for treating osteoarthritis that occurs with the presence of synovitis.
Bischofiteoil derivative, saline extracted from drilling oil wells. It gained its fame thanks to drills that were the first to be aware of its therapeutic effect in osteoarthritis. While working in oil wells, the drillers experienced resorption of arthritic nodules on their hands from constant contact with oil solution. Later it was found that Bischofite has a moderate anti-inflammatory and analgesic effect and also has a warming effect that causes a feeling of pleasant warmth.
Medical bilenatural bile from cows or pigs' gallbladder. Bile has an absorbent and warming effect and is used in the same case as bischophyte, but it has some contraindications: it can not be used for pustular skin diseases, inflammatory diseases of lymph nodes and ducts and fever with an increase in body temperature.
5. In-articular injections (injections into the joint):
Intra-articular injections are often used to provide emergency treatment for osteoarthritis of the knee joint. In many cases, intra-articular injection can actually alleviate the patient's condition. But at the same time, injections into the joint with osteoarthritis are performed much more often than is actually necessary. It is about this wrong, in my opinion, trend, which I will talk about in more detail.
Most often, preparations of corticosteroid hormones are injected into the joint: triamcinolone, betamethasone, hydrocortisone.
Corticosteroids are good because they quickly and effectively suppress pain and inflammation in synovitis (swelling and swelling of the joint). It is the rate at which the therapeutic effect is achieved that is the reason why corticosteroid injections have gained particular popularity among doctors.
However, this led to intra-articular injections of hormones beginning to be performed even without real need. For example, I have repeatedly encountered the fact that hormones were injected into a patient's joint for prophylactic purposes to prevent further development of osteoarthritis.
The problem, however, is that only osteoarthritis by itself, corticosteroids do not cure and can not cure them. This means that they can not prevent the development of osteoarthritis! Corticosteroids do not improve the condition of articular cartilage, strengthen bone tissue or restore normal circulation.
All they can do is reduce the body's inflammatory response to a specific injury in the joint cavity. Therefore, it makes no sense to use intra-articular injections of hormonal drugs as an independent method of treatment: they should be used only in the complex treatment of osteoarthritis.
For example, a patient has stage II gonarthrosis with joint swelling due to accumulation of fluid in it. Accumulation of fluid (synovitis) makes it difficult to perform medical procedures: manual therapy, gymnastics, physiotherapy. In such a situation, the doctor performs an intra-articular injection of a hormonal drug to eliminate synovitis, and a week later proceeds to the rest of the active therapeutic measures - this is the right approach.
Let us imagine another situation. The patient also has stage II gonarthrosis, but without fluid retention and joint edema. Should I inject corticosteroids into the joint in this case? Of course not. No inflammation - no "effect point" for corticosteroid hormones.
However, although intra-articular administration of corticosteroids is really necessary, a number of rules must be followed. First, it is undesirable to make such injections in the same joint more often than once every two weeks. The fact is that the administered drug does not "work" with full force immediately, and the doctor will be able to finally assess the effect of the procedure right after 10-14 days.
You should also know that the first injection of corticosteroids usually provides more relief than the next. And if the first intra-articular injection of the drug did not work, it is unlikely that the second or third injection of the same drug at the same site will give it. If the first intra-articular injection is ineffective, you should either change the medicine, or if the change of medication did not help, choose the more precise injection site.
If the introduction of a corticosteroid into the joint after this did not give the desired result, it is better to abandon the very idea of treating this joint with hormonal drugs. In addition, it is generally highly undesirable to inject hormones into the same joint more than four to five times, otherwise the likelihood of side effects increases markedly.
Unfortunately, in practice one has to deal with the excessive "determination" of doctors who repeatedly inject corticosteroids into the same joint without achieving at least a minimal effect with the first three injections. Two similar cases affected me more than others.
One of the patients received "only" ten Kenalog injections, and the procedure was performed daily, even without the prescribed ten-day break required to evaluate the results of the injection. And the other patient was injected with hormones inside the knee joints observing the interval (albeit only 3 to 5 days), but at the same time the poor guy received 25 to 25 injections of corticosteroids in one joint during the treatment!
It seems that the doctor "went too far" - nothing big. Can there be harm in such treatment? It turns out that it can!
First, with each injection, the joint, although insignificant, is damaged by the needle. Second, with intra-articular injection, there is always some risk of infection in the joint. Third, frequent injections of hormones cause a violation of the structure of the ligaments and the surrounding muscles, causing a relative "looseness" of the joint.
And most importantly, frequent injections of corticosteroids worsen the condition of those patients in whom joint injuries are combined with diabetes mellitus, high blood pressure, obesity, kidney failure, gastric or intestinal ulcers, tuberculosis, purulent infections and mental illness. Even injected exclusively into common cavities, corticosteroids have an effect on the whole body and can aggravate the course of these diseases.
It is much more useful to inject hyaluronic acid preparations (another name for hyaluronic acid is sodium hyaluronate) into the knee joint affected by osteoarthritis. They went on sale about 15 years ago.
Hyaluronic acid (sodium hyaluronate) preparations are also called "liquid prostheses" or "liquid implants" because they act as a healthy synovial fluid on the joint - that is, as a natural "joint lubricant".
Hyaluronic acid preparations are very useful and effective drugs: sodium hyaluronate forms a protective film on the damaged cartilage, which protects the cartilage tissue from further destruction and improves the sliding of the cartilage surfaces that come into contact.
In addition, hyaluronic acid preparations penetrate deep into the cartilage and improve its firmness and elasticity. Thanks to hyaluronidase, "dried" and thin cartilage with osteoarthritis regains its shock-absorbing properties. As a result of weakening of the mechanical overload, pain in the sore knee joint decreases and its mobility increases.
At the same time, injected correctly into the joint cavity, hyaluronic acid preparations practically do not cause side effects.
Treatment with hyaluronic acid preparations is performed during the course: in total, the course of treatment requires 3-4 injections in each sore knee, the interval between injections is usually from 7 to 14 days. If necessary, the course is repeated after six months or a year.
From my point of view, the biggest and only serious disadvantage of hyaluronic acid preparations is their high price. So in 2020, hyaluronic acid is mainly presented on imported drugs in our market.
However, when I return to the question of saving, I would like to note that despite the relatively high cost of preparations for hyaluronic acid, their use literally made it possible to "put on the legs" many of the patients who before the appearanceof these drugs would definitely need surgery.
And given the cost of joint surgery, it turns out that timely use of hyaluronic acid (even for several years) in any case and in every sense costs the patient much cheaper than knee replacement surgery. Of course, provided that the physician making such injections knows the injection technique.
This is important to know: Hyaluronic acid preparations are instantly destroyed in the joint where inflammatory processes are pronounced. Therefore, it is practically useless to administer them to those patients where gonarthrosis occurs on the background of an active stage of arthritis. But on the other hand, it is useful to use them in case of persistent remission of arthritis to treat the phenomenon of secondary gonarthrosis.
With primary gonarthrosis, you also need to be aware of such moments. For example, if the patient's joint "bursts" from accumulation of excess pathological fluid, it makes sense to first "turn off" the symptoms of synovitis (inflammation) and remove the excess pathological fluid by means of a preliminary intra-articular injection of hormones or takingnon-steroidal anti-inflammatory drugs. And only then should hyaluronic acid be injected into the joint, free of inflammatory elements.
In addition to corticosteroid hormones and hyaluronic acid preparations, attempts are being made to inject various chondroprotectors into the joint.
However, these drugs are several times inferior in effectiveness than hyaluronic acid preparations. They help a maximum of 50% of patients, and it is impossible to guess in advance whether the effect of their use will be or not. In addition, the course of treatment requires 5 to 20 injections into the joint, which, as we said, is fraught with possible damage to the joint and various complications.
6. Manual therapy and physiotherapy:
Manual therapy for stage I and II gonarthrosis often gives excellent results. Sometimes a few procedures are enough for the patient to feel significant relief. Manual treatment of the knee joint helps especially well if it is combined with stretching the joint, taking chondroprotectants and intra-articular ostenil injections.
This combination of treatment procedures is in my opinion much more effective than the many physiotherapy measures offered in any clinic. Let me give you an example from practice.
A case from the practice of a physician.
A 47-year-old woman with osteoarthritis of the right knee joint in phase II came to the appointment. When we met, she had been ill for 5 years. Over the years, the woman managed to experience all possible methods of physiotherapy that can only be offered in our outpatient clinics: laser, magnetotherapy, ultrasound, phonophoresis, etc. Despite the efforts of all physiotherapists, the condition of the patient's joints continued to deteriorate. - and this is natural, since, for example, chondrophobic protectors were only prescribed to a woman once in a short course for all five years.
Absolutely desperate, the woman decided to take extreme measures - she underwent a course of treatment with burning wormwood cigarettes according to the Eastern method. As a result, the knee was covered with burning scars but did not move better. Yes, and could hardly - despite all my respect for oriental medicine, I understand that wormwood moxibustion can not eliminate bone deformities and increase the distance between the bones that articulate at the knee.
After the woman was not helped by numerous physiotherapeutic procedures and even cauterization with wormwood cigarettes, she practically accepted surgical treatment. But then I changed my mind and decided to try the complex method I suggested.
The first treatment session was, as they say, "with a squeak" - we only managed to "touch" the joint a bit using manual mobilization. Therefore, we appointed the next session after initial preparation: for 3 weeks the woman took chondroprotectors, did self-massage and compressed with Dimexidum. After 3 weeks, I started mobilizing the joint again and then repositioned the joint by manual manipulation. There was a click, and suddenly the joint began to move much easier and more freely. The woman felt a clear relief.
In the next two sessions, we consolidated using the mobilization the improvement achieved, after which we consolidated the success with two intra-articular injections of Ostenil. And after a month and a half from the start of our not very intensive treatment (after all, we only needed six sessions), the woman was finally able to shed her wand, which had bored and began to move quite freely.
Two years have passed since then. Twice a year, the patient takes chondro protectors for a short course and occasionally comes to me for a follow-up appointment, where I am happy to note that the condition of the knee only gets better from year to year. And now even the first stage of osteoarthritis would be very difficult to assume - the patient's knee joint is almost completely restored.
Thus, only six treatment sessions (manual therapy plus intra-articular ostenil injections) in combination with a course of chondroprotectants proved to be more effective than five years of physiotherapy.
From this story (and by no means the only one of its kind) it becomes clear why I consider physiotherapy important, but only an additional part of the treatment program for gonarthrosis. In this sense, I like laser therapy, thermal treatment (ozokerite, paraffin treatment, therapeutic mud) and especially cryotherapy (treatment with local cooling) more than other procedures.
Diet for osteoarthritis is also very important.
8. Using a cane:
By relying on a stick while walking, patients with osteoarthritis of the knee joints seriously help with their treatment, as the stick takes 30-40% of the load intended for the joint.
It is important to choose a stick according to your height. To do this, stand up straight, lower your arms and measure from your wrist (but not your fingertips! ) To the floor. This is the length that the sugar cane should be. When buying a stick, pay attention to its end - it must be equipped with a rubber nozzle. Such a stick is shock-absorbing and does not slip when resting on it.
Remember that if your left leg hurts, the stick should be held in your right hand and vice versa. When taking a step with a sore leg, transfer part of the body weight to the stick.
9. Therapeutic gymnastics:
The main method of treating osteoarthritis of the knee joint is special therapeutic exercises. Almost no one with gonarthrosis can achieve real improvement without therapeutic exercises.
In fact, it is in no other way possible to strengthen muscles, "pump" blood vessels and activate blood flow as much as this can be achieved through special exercises.
At the same time, the doctor's gymnastics is almost the only treatment method that does not require financial costs for the purchase of equipment or medicine. All the patient needs is two square feet of free space in the room and a blanket or rug thrown on the floor.
You do not need anything other than the advice of a gymnastics specialist and the patient's desire to do this gymnastics. It is true that most ailments do not burn out of just such a desire. Almost every patient in whom I diagnose osteoarthritis must be literally persuaded to participate in physical therapy exercises. And most often, it is only possible to convince a person when it comes to an unavoidable operation.
The second "gymnastic" problem is that even those patients who are set on physiotherapy often cannot find the necessary sets of exercises. Of course, there are brochures for sale to patients with osteoarthritis, but the competence of a number of authors is questionable - after all, some of them do not have a medical education.
This means that such "teachers" do not always themselves understand the importance of individual exercises and the mechanism of their action on sore joints. Gymnastics complexes are often thoughtlessly copied from one brochure to another. At the same time, they contain such recommendations that it is absolutely right to grab the head!
For example, many brochures instruct a patient with osteoarthritis of the knee joint to "do at least 100 squats a day and walk as much as possible. "
Often patients follow such advice without first consulting a doctor and then sincerely wonder why they got worse. Well, I will try to explain why the condition of sore joints from such exercises usually only worsens.
Let us think of a collection as a bearing. Damaged by osteoarthritis, the diseased joint has already lost its ideal shape. The surface of the "bed" (or cartilage) is no longer smooth. In addition, cracks, caves and "burrs" appeared. Plus, the lubricant inside the sphere was thickened and dried up, it was clearly not enough.