More Boomers in The Gym


This is an excerpt from an article that appeared in the May 26, 2009 edition of the Wasington Post and was then picked up by the American College of Rheumatology.

Those of us who are Boomers (and I’m one of them since my birthdate was in August of 1949), want to stay young. fit, healthy, and in shapte.  Sixty is the new 30, as they say… 

This is one reason why the field of regenerative medicine with the use of PRP and stem cells is picking up momentum.  We all want to feel as good as we look!

 

More baby boomers joining gyms to improve health.

The Washington Post (5/26, Gowen) reports, “With the baby boomers’ impact on demography, people older than 55 make up the fastest-growing segment of the fitness industry, and more gyms are adding programming especially for them. In places where hip-hop once blasted as buff bodies hefted weights, a grayer clientele is signing up for yoga and aquatics classes, or exercising on recumbent bicycles and elliptical machines designed for older bodies.” Joe Moore, chief executive of the International Health, Racquet and Sportsclub Association, said, “It’s a natural trend as this segment of the population ages. … We’re seeing many [seniors] going to health clubs because of the health benefits, and not just the aesthetics of looking better.” Notably, the “association estimates that there were nearly 10 million health club members older than 55 in 2007, up from two million in 1990. Nearly a third of the member clubs now have senior programming.”




Is Prolotherapy Something You Should Consider?


Prolotherapy is type of treatment where dextrose (sugar water) is injected into a tendon, ligament, or joint.  The dextrose acts as a “proliferant” to induce inflammation.

This artificially created inflammatory response then leads to increased blood flow and migration of inflammatory cells into the area.  The end result is acceleration of the healing process and creation of stronger connective tissue.

An added plus is that symptoms of pain also improve.

Prolotherapy has been used to treat chronic tendonitis, whiplash, fibromyalgia, sports related injuries, ligament tears, back and neck pain, osteoarthritis, degenerative disc disease, sciatica, and temperomandibular joint dysfunction (TMJ syndrome).

Multiple treatments are often required.

Prolotherapy has been referred to as the “poor man’s PRP”.

In the right hands, prolotherapy is very effective and has been shown to be a cost effective solution for the treatment of many soft tissue injuries.




Gene Therapy For Patients With Rheumatoid Arthritis?


[The first study looking at gene therapy for RA was done by Targeted Genetics in Seattle, Washington.  Their results have been published in a number of journals and presented at a number of conferences.  The Targeted Genetics product looked at a method for transferring a gene for anti-tumor necrosis factor via an adeno-associated virus.  The preliminary data looked very promising.  This study on an anti-IL-1 gene transfer model also looks promising. NW]

Date: 1/26/2009
BIDMC Contact: Bonnie Prescott
Phone: (617) 667-7306
Email: bprescot@bidmc.harvard.edu

BOSTON — Researchers have reported the first clinical evidence that gene therapy reduces symptoms in patients with rheumatoid arthritis, an important milestone for this promising treatment which has endured a sometimes turbulent past. Described in the February issue of the journal Human Gene Therapy the findings stem from a study of two patients with severe rheumatoid arthritis conducted in Germany and led by an investigator at Beth Israel Deaconess Medical Center (BIDMC).

Originally conceived as a means of treating genetic diseases, such as cystic fibrosis and hemophilia, gene therapy involves implanting a normal gene to compensate for a defective gene in the patient. The first clinical trial to test gene therapy was launched in 1990 for the treatment of a rare, genetic immunodeficiency disease.

“This study helps extend gene therapy research to nongenetic, nonlethal diseases,” explains principal investigator Christopher Evans, PhD, Director of the Center for Advanced Orthopaedic Studies at BIDMC. “Rheumatoid arthritis [RA] is an extremely painful condition affecting multiple joints throughout the body. Arthritis is a good target for this treatment because the joint is a closed space into which we can inject genes,” adds Evans, who is also the Maurice Muller Professor of Orthopaedic Surgery at Harvard Medical School.

A classic autoimmune disease, RA develops when, for unknown reasons, the body’s immune system turns against itself, causing joints to become swollen and inflamed. If the disease is inadequately controlled, the tissues of the joint are eventually destroyed. Although anti-inflammatory agents and biologics can help to mitigate symptoms, there is no cure for the condition, estimated to affect more than 2 million individuals in the U.S. alone.

Evans has spent many years studying the molecules responsible for the breakdown of cartilage in patients with arthritis, identifying interleukin-1 as a good target. But, he adds, once he had this answer, another question was not far behind: How could he effectively reach the joints to block the actions of this protein?

Gene therapy provided the answer.

By implanting a gene in the affected joint, he was able to stimulate production of a human interleukin-1 receptor antagonist protein, which serves to block actions of the interleukin-1 protein.

“The idea is that by remaining in place, the new gene can continuously block the action of the interleukin-1 within the joints,” says Evans. “In essence, the gene becomes its own little factory, continuously working to alleviate pain and swelling.”

In 2005, in a study published in the Proceedings of the National Academy of Sciences (PNAS), Evans and colleagues demonstrated that the IL-1Ra gene could be safely transferred to human joints in patients with RA. In this new paper, the authors aimed to prove that the therapy was not only safe, but that it was of therapeutic benefit.

Two study subjects were recruited. (The number reduced from six study subjects following severe adverse events in an unrelated gene therapy trial taking place elsewhere, according to Evans.) Both subjects were postmenopausal females under the age of 75 with a diagnosis of advanced rheumatoid arthritis. After tissue was removed from the subjects’ knuckle joints, a harmless retrovirus was inserted into the tissue cells, in order to serve as a “vector” to transport the gene into the patients’ joints. After being placed in culture to grow and replicate, the cells were injected back into the afflicted joints

After four weeks, patients reported reduced pain and swelling, according to Evans. “In one of the two subjects, these effects were dramatic, and the gene-treated joints remained pain-free even though other joints experience flares.” Subsequent laboratory tests showed that tissues removed from the subject’s joint tissue synthesized lower amounts of disease-related proteins, confirming that the reduction in pain and swelling resulted from the actions of the implanted gene.

“Existing treatments for rheumatoid arthritis are costly and need to be administered regularly,” says Evans, adding that in addition to risk of side effects, not all patients respond well. “This paper provides us with the first real evidence that painful symptoms can indeed be lessened through gene therapy.”

Ongoing work will focus on the use of gene therapy for the treatment of osteoarthritis, as well as rheumatoid arthritis.

This study was funded, in part, by grants from the National Institutes of Health and Orthogen, a German biotechnology company.

Study coauthors include Peter Wehling, Julio Reinecke, Axel Baltzer, Marcus Granrath, Klaus Schulitz, Carl Schultz, and Rudiger Krauspe of the University of Dusseldorf School of Medicine, Germany; Theresa Whiteside, Elaine Elder and Paul Robbins of the University of Pittsburgh School of Medicine; and Steven Ghivizzani of the University of Florida College of Medicine.


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FDA Approves New Anti-TNF drug


The FDA approved the use of Cimzia, an injectable drug, on Wednesday, May 13, 2009. Cimzia is manufactured by UCB, a company based in Belgium.

The Food and Drug Administration approved the drug for patients with moderate to severe rheumatoid arthritis. The injectable medication was previously approved to treat Crohn’s disease in April, 2008.

Cimzia is the fifth tumor necrosis factor blocker approved in the U.S. The three other products are Humira (Abbott), Remicade (J&J), Enbrel (Wyeth/Amgen), and Simponi (J&J).

The drugs all work by targeting and neutralizing a protein called tumor necrosis factor which plays a pivotal role in causing inflammation and damage to joints and internal organs.

Patients will inject themselves with the drug.  One advantage that Cimzia has is a syringe designed for arthritis patients.  UCB, collaborated with a consumer product manufacturer, OXO Products, to design a pre-filled syringe with oversized finger grips and a rounded needle cap.  This will make it easier for patients to uncap and inject the drug.

Cimzia was approved, based on data from four  clinical trials, involving more than 2,300 patients.  The combination of Cimzia and a disease-modifying drug, methotrexate,  significantly reduced arthritis signs and symptoms after six months.  The drug combination also slowed progression of joint damage. Longer term data is being evaluated.  Data has also been collected on functional improvement measures.

Cimzia also has a relatively flexible dosing schedule, in which the drug is injected every two or four weeks.

Previously approved drugs like Enbrel and Humira are injected every one or two weeks.

The side-effect profile of Cimzia is similar to that of other TNF-inhibitors.  There appears to be less discomfort at the injection site compared with Enbrel and Humira.  It appears the major competitor for Cimzia will be Simponi, which is injected once a month.




Acupuncture, Whether By Needle Or Toothpicks, Helps Back Pain


[This new post is from Healthday, a great health portal.  It summarizes the results of a recent study done on the effects of acupuncture in back pain.  The consensus among those of us in practice is that acupuncture works.  We just don’t know why or how.  This artricle presents a surprising take…NW]

Acupuncture, Real or Fake, Eases Back Pain
By Amanda Gardner
HealthDay Reporter

TUESDAY, May 12 (HealthDay News) — Any kind of acupuncture, whether it pierced the skin or not, eased chronic lower back pain in a group of adult patients.

“All were superior to usual care,” said Daniel Cherkin, lead author of a report published in the May 11 issue of the Archives of Internal Medicine. “Acupuncture is an effective treatment for chronic back pain. People receiving acupuncture are more likely to get better.”

But the unusual finding that non-penetrating acupuncture did as well as acupuncture that used standard needles will raise questions about how this works, added Cherkin, who is a senior investigator with the Group Health Center for Health Studies in Seattle.

Chronic back pain is a chronic health issue in the United States, and is the top reason why patients go to acupuncturists, often when traditional therapies disappoint.

Although there have been previous studies on whether acupuncture represents a viable treatment option, “the evidence of the value of acupuncture in general is very murky because the quality of the research is not very good,” Cherkin said.

This trial, the largest randomized one of its kind, was funded by the National Center for complementary and Alternative Medicine, part of the U.S. National Institutes of Health.

More than 600 adults with chronic lower back pain were randomized to one of four study arms: individualized acupuncture, standardized acupuncture, simulated acupuncture (non-penetrating) or “usual care.”

In the simulated acupuncture group, practitioners mimicked needle acupuncture by using a toothpick in a needle guide tube — poking at traditional pressure points without breaking the skin.

Participants received 10 treatments over seven weeks, at the end of which dysfunction and symptom scores improved equally among the three treatment arms.

Also, medication use in all the acupuncture groups decreased immediately and over the next year. About two-thirds of patients were taking medication, mostly painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs). By eight weeks, that had declined to 47 percent in the acupuncture groups and 59 percent in the usual-care group.

There were no cost savings for the health plan (treatments were estimated to cost from $600 to $1,200).

But the real surprise was that acupuncture was effective even when the treatment didn’t break the skin. “It’s not necessary to penetrate the skin. There’s no advantage to tailoring and no advantage to using a needle. Why?” Cherkin said. “It throws open the question of how does this work.”

There are no answers to that question yet, but some theories persist. It’s possible that the “superficial” acupuncture still kicks off a cascade of physiological processes that result in relief, the authors wrote. Or the benefit may come from “nonspecific effects such as therapist conviction [or] patient enthusiasm.”

Some previous studies have found similar physiological responses from both types of acupuncture.

Janet Konefal, a licensed acupuncturist and assistant dean for complementary and integrative medicine at the University of Miami Miller School of Medicine, said she was not surprised that non-puncture stimulation had equal effects.

“You can stimulate a point with pressure, needle, electricity, even now with laser light and different frequencies of laser light,” she said. “‘Pecking’ on a point is a Japanese technique for stimulation. You might use that with someone who is older or weak in their constitution. That could explain why two different methods of stimulation work equally well.”

Acupuncture of all types is “well on its way to the mainstream,” Konefal said. “When we understand that different stimulations may be effective rather than doing deep-needle stimulation which, for some people when in pain can be painful, we can now use laser or light needling or even just electric stimulation on the points; I think that part is great.”

And, Cherkin pointed out, “just because you don’t understand how it works doesn’t mean it doesn’t work. It could be worthwhile to pursue it.”

More information

The U.S. National Center for Complementary and Alternative Medicine has more on acupuncture.

SOURCES: Daniel Cherkin, Ph.D., senior investigator, Group Health Center for Health Studies, Seattle; Janet Konefal, licensed acupuncturist and assistant dean, complementary and integrative medicine, University of Miami Miller School of Medicine; May 11, 2009, Archives of Internal Medicine




Computers… Harmful to Your Health If You Have Arthritis


[This was an interesting article that was published in MedPage.  Since so many people suffer from these conditions and many of them also work on computers, I though putting this up on the blog made sense. NW].

 Arthritis Patients Cite Computer Problems

By Todd Neale, Staff Writer, MedPage Today
Published: May 08, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

 

LITTLE FALLS, N.J., May 8 — About three-quarters of patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia reported some discomfort while using a computer, a survey revealed.

An even higher proportion , 84%, reported a problem with computer use stemming from their condition, Nancy Baker, Sc.D., of the University of Pittsburgh, and colleagues reported in the May issue of Arthritis Care & Research.

“The extent of problems is of concern due to the effect that these limitations may have on [the patients’] ability to use a computer for work-related tasks . . . and the increased risk of people with arthritis developing musculoskeletal disorders of the upper extremity related to computer use,” the researchers said.

Individuals with arthritis should evaluate their home and work computer environments to identify ways to reduce problems, they said.

In addition, they said, “health professionals must work with people with arthritis to identify problems experienced during computer use and implement computer workstation modifications to ensure safe, effective, and comfortable use of all computer equipment.”

Because of their condition, many arthritis patients choose less physically demanding jobs, such as administrative or clerical positions, the researchers noted.

Today, these jobs often involve extensive computer time, but little is known about the problems arthritis sufferers face in a computer-based work environment.

So Dr. Baker and colleagues surveyed patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia about their computer use and associated problems. The questionnaire, a letter explaining the survey study, and a return envelope were mailed to 1,190 people in the Registry (including 502 with rheumatoid arthritis, 406 with fibromyalgia, and 282 with rheumatoid arthritis).

Three hundred and fifteen responded. Of the 84% who reported a problem with computer use related to their condition, most had difficulties with their chairs — such as having a hard time getting comfortable, standing up, or sitting down. They were followed by problems with the keyboard, mouse, and monitor.

Surprisingly, patients with fibromyalgia reported significantly more problems involving the keyboard (P=0.009), mouse (P=0.002), and monitor (P=0.009) than those with rheumatoid arthritis or osteoarthritis.

“Based on the type of impairments characteristic of each disorder, those with rheumatoid arthritis and osteoarthritis should have reported more problems with the keyboard and mouse than those with fibromyalgia,” the researchers said.

They proposed three possible explanations for this:

“People with fibromyalgia may have increased clumsiness related to abnormalities in sensory processing or fatigue, the presence of diffuse rather than localized pain may result in problems in manipulation, or those with movement limitations may have found methods to adapt their environment more easily than those with diffuse pain, resulting in fewer perceived problems,” they wrote.

Overall, 76.5% of the survey respondents reported some discomfort while using a computer. The offending pieces of equipment were most often the chair (54.9%), keyboard (50.5%), and mouse (49.5%).

“Because those with arthritis may experience pain and discomfort even under ideal circumstances, it is not surprising that the prevalence of respondents reporting discomfort with computer use is considerably higher than the general population of computer users,” the researchers said.

Reported rates of discomfort for the general population range from 10% to 55%.

Compared to patients with other diagnoses, those with rheumatoid arthritis reported significantly lower levels of discomfort with the chair (P=0.002), and those with fibromyalgia reported significantly higher levels of discomfort with the monitor (P<0.001).

The researchers acknowledged limitations of the study, including possible selection and nonresponse rate bias (65%), which varied by diagnosis. In fact, rheumatoid arthritis patients were twice as likely to respond as the others.

They authors suggested that the differential response rate “may have also overestimated the prevalence of problems in one or more groups. It is quite likely that nonrespondents either used a computer very little or had few perceived computer use problems. Respondents with severe impairments may not have responded because their impairments precluded computer use.”

In addition, they noted the fact that the survey did not account for differences in computer usage patterns, environmental factors such as the setup of the workstation, or the psychosocial environment.

The study was supported by a Chapter grant from the Arthritis Foundation of Western Pennsylvania. Dr. Baker’s work was supported by the Arthritis Foundation, Western Pennsylvania Chapter.

The authors did not report any conflicts of interest.

 Baker N, et al “Problems experienced by people with arthritis when using a computer” Arthritis Rheum 2009; 61: 614-22.




What’s new for gout…


Rheumatologists typically use drugs that either reduce the amount of uric acid a patient is making… or they give them a drug that makes them pee the uric acid out. The target is to get the uric acid in the blood down to 6mg/dL.

Probenecid is the drug of choice to make patients pee the uric acid out.  It is generally safe but shouldn’t be used for patients with abnormal kidney function, a history of kidney stones, during aspirin therapy, and in those who already pee out a lot of uric acid.  Patients should drink plenty of fluid.

Benzbromarone is a drug that also acts as a uricosuric agent (makes patients pee uric acid out).  It is not FDA-approved.  And, unfortunately, it can be extremely toxic to the liver.

Allopurinol is a drug that suppresses uric acid production. While it’s effective, it’s also potentially toxic with side-effects including severe rash, liver damage, bone marrow toxicity, and hypersensitivity.  It should be started at a low dose and slowly increased.

Patients started on either probenicid or allopurinol often have flares of gout. Therefore, they should also be treated with colchicine, a drug that prevents flares of gout in patients who are started on anti-gout meds. Once the target uric acid level is achieved and maintained for 6 months, colchicine prophylaxis can be discontinued.

Febuxostat is a new alternative to allopurinol.  It was FDA approved in March 2009 and marketed as Uloric. Uloric is an oral tablet that comes in both 40 mg as well as 80 mg strengths. Allopurinol is excreted primarily by the kidney while febuxostat is metabolized by the liver. Therefore, febuxostat can be administered in patents with less than normal kidney function.

Its efficacy at attaining a serum uric acid level of 6.0dL  or better and  side-effect profile seems to be somewhat better than that of allopurinol, and is an alternative to allopurinol in patients who are allergic to that drug.  The only drawback is that there may be a higher incidence of cardiovascular events in patients taking high dose febuxostat.

Uricase is a substance that breaks down uric acid. It’s used in Europe to prevent the high levels of uric acid that can occur in the blood of patients with cancer who are receiving chemotherapy and also in some patients with treatment-refractory gout.

A recombinant form of uricase made from a fungus, called Aspergillus, has been FDA-approved for use in patients undergoing chemotherapy who may develop massive amounts of uric acid in the blood with treatment. The problem is that it induces significant immune reactions in patients and can cause anaphylactic shock.

A type of uricase preparation linked to polyethylene-glycol is currently being studied in clinical trials for gout.

The angiotensin receptor blocker losartan (Cozaar), used for hypertension, and the triglyceride-lowering agent fenofibrate (Tricor) have moderately potent uricosuric effects.

One study of 10 patients with severe gout treated with the anakinra, a drug that blocks a protein messenger called IL-1, substantially reduced pain in all patients within two days, without side effects. Clinical signs of inflammation were reduced in 9 of 10 patients by the third day of treatment.

So… the future looks pretty bright for this old disease.  Right now I’m using alot of febuxostat because I have quite a few patients with gout who’ve had allergic reactions to allopurinol.  Plus, alot of people with gout have less than normal kidney function, so it’s nice to have a drug where that isn’t quite such an issue.




New drug for rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis


Simponi (golimumab) was just approved by the FDA for the treatment of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.  This is the first drug (to my knowledge) that was approved for all three indications at one time.

Simponi is a TNF-inhibitor, similar to Enbrel, Humira, and Remicade.  It’s a human monoclonal protein directed against TNF. The major difference is that it is administered subcutaneously once a month.

The precautions and potential side-effects are similar to that of other TNF-inhibitors.  The drug is manufactured by Centocor, a subsidiary of Johnson and Johnson. There is a patient assistance program available.

With the trend towards more self-injectables, this is a good addition.

More information is available at www.SIMPONI.com.

Other drugs in the wings for RA include Cimzia, a PEGylated- TNF inhibitor, and Actemra, an IL-6 inhibitor.




Psoriatic arthritis: Methotrexate and biologic therapy


I recently had a question from a person with psoriatic arthritis who had had a couple of rheumatologists differ in their approach to the condition.  He asked my opinion. This was my reply:

 

My approach to psoriatic arthritis is:

 

  1. Stage the disease by getting an MRI with gadolinium of the most affected area
  2. Begin Methotrexate (MTX) ASAP
  3. Add on a TNF inhibitor fairly quickly (within the first 6-12 weeks)
  4. There are no significant differences between Enbrel and Humira as far as side-effects; however, I feel both Humira and Remicade act faster on both the skin and joint manifestations of psoriatic arthritis than does Enbrel
  5. All TNF inhibitors carry with them the possibility (and I stress the word “possibility”) of reactivation TB, susceptibility to fungal infections such as histo, cocci, etc.
  6. I have my patients hold their MTX and TNF inhibitors if they have an active infection of any type (skin, URI, UTI, etc.) until the infection is cleared.

 

He asked another question about malignancy risk with MTX and TNF inhibitors. 

 

My answer was:

 

MTX is not associated with malignancies above and beyond what would be expected due to arthritis alone.

 

The data regarding TNF inhibitors is still not completely clear. Like every effective medication, there are risks and benefits.

 

Only you, as the patient, can make the final decision.

 

The point is that we don’t know about malignancy risk with TNF inhibitors.  While the data so far looks relatively good so far, we don’t know what can happen 20 to 30 years down the road.  Nonetheless, in diseases like RA and psoriatic arthritis, the risks of the disease (early cardiovascular complications such as heart attack and stroke, shortened life expectancy, etc.) appear to far outweigh the risks of malignancy… at least for now.




"Ooohhh… My Aching Knee!!!" Insider Secrets on How You Can Get Relief Quickly and Easily!


When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.

Know Your Knee!

The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.

Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.

Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a “torn cartilage”.

There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.

Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.

Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.

Is it bursitis… or tendonitis…or arthritis?

Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.

Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.

Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.

The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.

Knock out knee arthritis… simple steps you can take! Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.

While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.

Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.

So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.

Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.

Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution… make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated… so buyer beware!

Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.

Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.

Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.

Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.


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