My Doctor Online The Permanente Medical Group

Symptoms

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The primary symptom of knee osteoarthritis is pain in the knee joint that gets worse when you are active and gets better with rest. If you have advanced osteoarthritis, you may also experience pain when you are resting. Symptoms usually progress gradually over time, although your symptoms may suddenly get worse if you aggravate your arthritis by doing too much or you injure your knee. Other common symptoms include:

Stiffness. It is very common to feel stiff, especially first thing in the morning. Stiffness usually lasts for about 30 minutes after you get up and can recur during the day if you are inactive for a while. Stiffness can make it difficult for you to go about your usual daily routine. For example, you may have difficulty:

• Walking
• Climbing stairs
• Squatting or kneeling
• Standing up after sitting on a chair
• Getting out of a bathtub

Tenderness. Touching the knee joint can be painful. Your knee may hurt to the touch even if there is no visible evidence of inflammation.

Swelling. Your knee joint may swell with fluid, as your body attempts to make up for the loss of cartilage. Sometimes there is so much fluid that it begins to build up in the back of the knee, a condition known as a Baker’s cyst.

Crackling or grating. You may feel a crackling or grating sensation when you move the joint. This is thought to be caused by roughening of the normally smooth cartilage inside the joint.

Bone spurs. You may be able to feel bone spurs under the skin near the affected joints. These get larger over time.

Causes and Risk Factors

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There are a number of factors that may increase your risk for developing osteoarthritis in any joint. Risk factors that make it more likely that you will develop osteoarthritis in the knee specifically include:

Kneeling and squatting. Work that requires frequent squatting and kneeling, such as construction and housework, may be a cause.  

Stress on the knee. This can be caused by:

• Heavy work. Carrying heavy items (tool belt, briefcase, purse, etc.) puts extra stress on the knees and hips, which causes more wear and tear on your joints. 
• Being overweight. Carrying extra weight on your frame also places extra stress on your knees, and it can cause you to develop arthritis at a younger age and worsen your symptoms if you already have arthritis.

Diagnosis

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We evaluate the results of a physical examination and your description of your symptoms in order to diagnose osteoarthritis of the knee. 

Medical history

We will ask you a number of questions about your symptoms: 

• What kind of work do you do? What kind of work have you done in the past? What sports and other hobbies do you participate in?
• Have you ever injured your knee?
• When and how did your symptoms start, and how have they changed over time?
• How much pain are you having, and does it come and go, or is it constant? 
• When do you feel pain or stiffness, and how long does it last?
• Do you feel a grinding or grating sensation when you bend or straighten your knee?
• Do you have family members who have experienced joint problems?
• What medications are you taking now? What medications have you taken in the past?  

Physical examination

During the physical examination, we will examine your knee and look for:

• Swelling or fluid around, or behind, the knee joint
• Tenderness over your knee
• Bony enlargement of the knee joint
• Any redness or warmth over the knee, which may indicate infection
• Loss of ability to fully bend or straighten your knee

Imaging studies

We will look at X-rays of your knee in order to determine how severe the osteoarthritis is. An X-ray can reveal a number of knee joint characteristics that can help us confirm osteoarthritis. These include:

• The space between the thigh bone and shin bone is narrowed due to the loss of cartilage.
• Bony spurs, also called osteophytes.
• Cysts on the bone.

Treatments

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Our goals for treatment are:

• To decrease your pain and minimize swelling.
• To improve the function of the knee.
• To help you maintain a healthy body weight.
• To improve your quality of life and help you achieve a healthy lifestyle.

There are a number of ways to treat osteoarthritis including exercise and physical therapy, weight management, medication, joint injections, and, in severe cases, surgery. We recommend a combination of treatments specifically for osteoarthritis of the knee joint.

Limit the activities that may aggravate your knee; for example, running, fast walking, carrying heavy items, and standing for extended periods of time.

Exercise and physical therapy

A combination of body-strengthening and aerobic exercise has been shown to reduce pain and improve quality of life. Gentle midrange movement makes arthritic joints feel more comfortable. Inactivity can make joints feel stiffer. Exercise can also improve your mood, energy levels, quality of sleep, weight control, heart health, and muscle tone and strength. It is important to choose the right kind of exercise and to limit activities that aggravate your knee. Running, fast walking, carrying heavy items, and standing for extended periods of time can all increase stress on the knee. We can help you choose the most appropriate form of exercise.

Physical therapy

Physical therapy may improve the flexibility of your knee joint and strengthen the muscles that support the knee. As part of your physical therapy, we will teach you exercises that avoid hurting the joint or causing you more pain. It is important that you continue these exercises at home to maintain your progress. A physical therapy plan for the knee usually includes:

• Exercises to strengthen the quadriceps, or main thigh muscles. For some individuals, this increases the stability and mobility of the knee joint and reduces pain.
• Aerobic exercise. We can help you choose the most appropriate form of exercise. For example, if you are a runner, we may suggest that you try swimming or cycling on a stationary bike instead to reduce impact on your knee.

Steroid injections

If oral pain medications are not effective, we may consider injecting the knee joint with steroid medication. Steroid injections can provide short-term improvement, usually for a few weeks to several months. We may repeat injections about every 6 months if they remain effective for you. Side effects of joint injections include pain and swelling after the injection. 

Surgery

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We may recommend surgery if less invasive treatments have not been effective. Surgical procedures for osteoarthritis include knee arthroscopy, total joint replacement, partial joint replacement, and osteotomy. 

Arthroscopic Surgery

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In many cases, we can evaluate and make some repairs to an arthritic knee joint using an arthroscope. This approach avoids the need for a large incision. An overview of this procedure includes the following:

• We make 2 or 3 small incisions in the knee joint. 
• We then insert an arthroscope – a lighted device with a camera and surgical instruments attached – into the joint itself. 
• The scope allows us to see the structures inside the knee and any debris, such as bone spurs and loose cartilage that have collected in the joint.
• We insert small instruments into the other incisions and use them to trim torn articular cartilage and/or remove debris that may be causing pain.  

Total Knee Replacement Surgery

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We may recommend replacing your knee joint entirely if your osteoarthritis has not responded to other medical treatments and is so severe that it is affecting your ability to perform everyday activities.

Total knee replacement is a very successful procedure that significantly reduces pain for many people and enables them to get back to the activities they enjoy. Replacement knee joints can last 15 years or more. How quickly they wear out will depend on the amount of pressure you put on your knee and how active you are.

Not everyone is a candidate for knee replacement surgery. We will consider a number of factors while evaluating you for this type of surgery. It is crucial that you, and your joints, are healthy enough to recover from surgery and participate in a comprehensive rehabilitation program.   

The replacement knee joint is usually made of metal and/or plastic and has 3 components:

• A femoral component that attaches to the femur. This is usually made with polished metal.
• A tibial component. This is the part that is attached to the top of the tibia. It is usually made of plastic and metal.
• Kneecap – or patellar – component.

The surgery

Knee replacement surgery takes between 1 and 3 hours. We usually perform the procedure using spinal anesthesia. You will be awake but numb from the waist down. Alternatively, we may recommend a general anesthetic.

During the procedure, we make a vertical incision along the kneecap. We then prepare the bones so that the replacement implants fit well. We do this by removing some of the bone from the ends of the tibia and the femur and then drilling small holes into the ends of those bones. Next, we install the replacement knee. We use a special bone cement to attach the joint. Finally, we close the incision with stitches or staples, which we usually remove 2 to 3 weeks after the surgery.

Recovery and rehabilitation

We will work with you to develop a graduated exercise program to restore mobility to your knee and to strengthen the muscles that stabilize the knee. We can advise you how and when to resume normal activities such as sitting, standing, and climbing stairs and discuss the most appropriate place for you to begin your rehabilitation. If you do not have anyone at home who can help you, we may recommend that you stay at a skilled nursing facility to begin your physical therapy. If you do go home, a physical therapist will visit for 4 to 6 weeks to make sure that you are progressing well. We will also talk to you about preventing falls. This is particularly important, as any fall can damage your new knee and require more surgery.

Partial Knee Replacement

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We may recommend a partial knee replacement if osteoarthritis has damaged only one area, or compartment, of your knee. During surgery, we replace only the damaged compartment of the knee – the medial, lateral, or patellar (kneecap) compartment. 

Partial knee replacement is a simpler and less invasive surgery that requires a smaller incision. You may recover and get back to your normal activities much more quickly than you would after a total knee replacement. We don’t usually recommend this procedure for younger, active patients as they are likely to put too much stress on the replacement, causing too much wear and tear. A partial replacement may be a good option for older slim patients who have less active lifestyles.

Osteotomy

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We may recommend a different procedure known as an osteotomy if you are young and not yet ready for a total knee replacement. Delaying a total knee replacement is particularly valuable for younger people because replacement knees tend to last, on average, about 15 years. Replacing your knee earlier in life may mean that you have to have knee replacement surgery several times during your lifetime. 

During the procedure, we remove a section of bone from your knee. Removing bone from a specific area of your knee pushes your weight onto an area of the joint that does not have osteoarthritis damage. For example, if you have lost more cartilage in your inner knee, we may remove bone from the outside of your tibia, closest to the knee. The resulting unevenness tips your body weight toward the outer knee, which has healthier cartilage.

Prevention

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Although you can’t prevent osteoarthritis, you can decrease your risk of developing severe problems in your knee. A few things that you can do are:

• Maintain a healthy weight. Carrying excess weight places extra stress on your knee. Talk to us about weight management resources and classes.
• Exercise. Regular exercise will keep your muscles strong and your ligaments flexible. Try exercises that do not stress your knee like swimming, stationary bicycling, elliptical machines, or water aerobics.
• Wear shoes that support and cushion your feet.
• Avoid falls at home by keeping your home well lighted, using handrails on staircases, and using sturdy ladders or foot stools if you need to reach for items on high shelves. Do not use a chair or step on the counters.
• Avoid prolonged and repetitive kneeling, squatting, or frequent knee bends.
• Use walking sticks if you have to walk up and downhill.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms. If specialty care is needed, your personal physician will arrange an appointment for you in my department.

We will ask you to come in 30 minutes before your appointment so that we can take X-rays of your knee. During your office visit, we will review those X-rays, discuss your symptoms, and I will examine your knee. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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