Given the challenges of recognizing and managing osteoarthritis in an aging but active population, this author offers a thorough review of current and emerging treatment options.

When it comes to conservative and non-conservative treatments in the orthopaedic arena, there have been a number of technological advances for a variety of orthopaedic disorders. In particular, advances in the treatment of osteoarthritis offer promise for aging athletes.

When we think of athletes, we think of people who may undergo rigorous training, people who may bring physical skill, strength and/or endurance to their chosen sport or sporting activity. In general, athletic pursuits offer a competitive challenge whether it is within a team environment or as more of an individual challenge. While most athletes strive for a high standard in these sports or activities, sports have changed over the years in regard to competition level as well as the level of training. Indeed, some athletes start participating and training as early as kindergarten.

Today, young and older athletes affected by osteoarthritis are becoming a large part of our patient population. They are in search of treatment for their sometimes disabling condition to “get them ready for the weekend softball game.” Others may simply seek to keep their pain at a manageable level so they can continue employment or participate in normal everyday activities of life.

Here one can see an AP weightbearing X-ray of a varus deformity (left) that demonstrates narrowing of the medial compartment. On the right is an AP flexed X-ray that demonstrates the posterior joint line contact of the medial compartment.

Although osteoarthritis (OA) can affect many joints of the body at any age, let us take a closer look at key treatment considerations for managing OA knee pain in aging athletes. Granted, in order to arrive at an effective treatment plan, clinicians must have a strong understanding of knee anatomy (see “Understanding The Dynamics Of Knee Anatomy” on page 17). One must also be aware of the possible etiologies of OA knee pain.

How Can Athletes Develop OA In The Knee?
Like any individuals, athletes face uncontrollable and controllable variables as possible etiological factors in developing OA. Indeed, OA can develop after an internal derangement or alteration to the knee joint. Uncontrollable variables may include metabolic factors, hormonal factors, congenital or acquired pes planus (flat feet), metatarsus adductus (adduction or vaurs deformity of the forefoot), pes cavus (high arch), potential neurological disorders, or a congenital deformity.1-5

Again, there are injuries that may occur from controllable variables. These variables may be an athlete’s particular sport, training, intensity, duration, frequency and level of competition.1,6 Osteoarthritis may also develop after an injury goes untreated. This may involve a meniscal or ligamentous disruption that alters the integrity of the knee. Additional factors may include obesity or lingering effects of past surgical techniques, including arthrotomy and/or arthroscopy for a total meniscectomy, ACL reconstruction, or management of an osteochondritis dissecans lesion (OCD).

Pertinent Pointers On Diagnosing OA In The Knee
Diagnosing OA can be a challenging hurdle for practitioners due to common symptoms of joint stiffness, swelling, warmth, decreased range of motion or quality of pain that mimic underlying conditions such as an acute/chronic meniscal tear, loose body, ligament tear, tumor or infection. Therefore, it is vital to obtain a detailed patient history including an observation of the patient’s gait and stance, onset of symptoms, known traumatic-type injury and mechanism, or any limitation in activity level. One should obtain this information prior to obtaining appropriate diagnostic tests including X-rays, MRIs, bloodwork, and/or fluid analysis after a knee aspiration.2,6-8

Clinicians should obtain X-rays in a three-dimensional (3-D) type perspective in order to visualize all compartments within the knee joint. A X-ray series would include weightbearing anterior (AP), lateral and bilateral patellofemoral views. Evidence of OA would include medial or lateral joint line narrowing, hypertrophic spur formation, bone sclerosis and/or flattening of the articular surfaces.

Here one can see a valgus deformity. Note the narrowing of the lateral compartment on the AP weightbearing X-ray.

If there is a question of bone to bone contact in an isolated compartment on the AP view, one should obtain a weightbearing posterior-anterior (PA) flexed view in order to visualize posterior joint line contact. While getting a MRI can aid in the diagnosis of OA, clinicians generally reserve MRI for identifying the presence of a meniscal tear, ligament disruption or an OCD lesion. Lab work and fluid aspiration would include a CBC, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), uric acid, cell count, culture and crystals.2

Other Considerations In Formulating A Treatment Plan
Even after you have established a diagnosis of OA, it is important to have an understanding of the athlete’s intention in regard to sports or athletic activities, his or her age, body habitus, and comorbidities. These considerations will also factor into one’s treatment perspective in managing OA.

Historically, treatment for OA stemmed from a trial of oral non-steroid antiinflammatories (NSAIDS), intraarticular corticosteroid joint injections; physical therapy to maintain joint mobility and strengthening; and surgery for a total menisectomy, high-tibial osteotomy (HTO) and/or total knee replacement. Today, technology has offered advantages via non-pharmacological and pharmacological interventions, physical therapy, bracing, and minimally invasive surgical procedures in the field of arthroscopy and knee replacements.

Accordingly, let us review the current and historical treatment regimens in regard to the aging athlete with OA knee pain.

Can Non-Pharmacological Products Have An Impact?
Over the counter (OTC) durable medical products purchased by the athlete may consist of a “universal” elastic knee sleeve, Ace bandage, arch supports, ice packs, heating or shoe wedges.4,5 Although these devices may offer some initial benefit in alleviating discomfort, support and symptom management are usually short-lived.
Shoe wedges may be a possible exception when it comes to facilitating long-term relief. A shoe wedge is an OTC product made of felt that one places underneath the inner or outer portion of the insole as it relates to the heel or back of the shoe. The theory behind the wedge is that it helps unload unilateral compartmental arthrosis, thus alleviating pressure or friction from opposing articular surfaces during weightbearing activities. In regard to companies that manufacture these wedges, one may locate them on the Internet. These companies include but are not limited to Alimed, Hapad and Midland Supply.

What About OTC Medications For OA Pain?
Consumers are faced with many pharmacological options including OTC topicals, orals and nutritional aids to help alleviate symptoms of OA. Topical preparations include agents like Ben-Gay, Aspercreme (Chattem) Icy Hot (Chattem) or capsaicin. Theoretically, these agents produce their effect by altering the skin surface primarily by increasing the warmth and via relaxation of muscle tightness. These options are usually self-limited because they do not penetrate deeply below the skin surface.2,4,6,9

Historically, oral medications for treating pain and discomfort include Tylenol® (Johnson and Johnson), aspirin, ibuprofen, Aleve® (Bayer) and vitamins. While these are safe to obtain without a prescription, it is important to urge patients to closely read the labeling instructions on proper dosing in order to avoid unwanted complications. When patients ask about these medications, clinicians should encourage them to be aware of potential toxicity, possible interference with prescription medications and contraindications due to underlying comorbid conditions such as glaucoma, hypertension, kidney or respiratory disorders.

There has also been a rise of alternative type supplements. The supplements commonly include Cosamin DS (Nutramax Labs), Bio-Flex and other supplements that offer chondroitin and/or glucosamine as ingredients. Although these supplements are not regulated by the Food and Drug Administration (FDA), and offer limited, supporting scientific data, the medications are advertised as being effective in helping to build and/or maintain the integrity of the articular cartilage, which reduces symptoms associated with OA. While some medical professionals have asked for more scrutiny of these supplements, scientific studies are beginning to show support and recommend the supplements as treatment options. That said, practitioners should be wary of recommending any non-FDA regulated alternative therapy due to potential known and unknown side effects.

What You Should Know About NSAIDs
Prescription medications for managing OA pain include traditional NSAIDs. Non-steroidal antiinflammatory medications emerged in the medical profession with a landmark discovery by Sir John Vane in 1971. He determined that aspirin’s mechanism of action inhibits cyclooxygenase (COX), an enzyme that converts arachidonic acid into prostaglandins.6 He began this tradition of using aspirin for its effects on the inflammatory process. Furthermore, Vane identified arachidonic acid as a 20-carbon fatty acid molecule, which, once it is released in the bloodstream, is rapidly metabolized along two pathways into potent mediators of inflammation: prostaglandins and thromboxanes. Therefore, traditional NSAIDs produce their effect via inhibition of the COX enzyme pathway, which facilitates the development of an inflammatory process.6

Although NSAIDs serve a purpose in managing symptoms associated with OA, the practitioner must be aware of potential adverse effects that involve the gastrointestinal, renal and coagulation systems prior to prescribing any form of NSAID.

One can see an AP flexed X-ray that demonstrates the posterior joint line contact of the lateral compartment.

For example, one may recommend acetaminophen (Tylenol) to some patients as it is considered a first-line medication for OA. However, one must educate the patient on avoiding a maximum of 4000 mg over a 24-hour period in order to prevent potential hepatotoxicity.

Celecoxib (Celebrex, Pfizer) is a COX-2 inhibitor. Unlike traditional NSAIDs that inhibit the COX gene, celecoxib’s mechanism of action for inflammation involves the inhibition of a fairly recently discovered COX gene referred to as the cyclooxygenase-2 or COX-2. According to animal research studies, celecoxib exhibits an antiinflammatory and anti-pyretic effect due to the inhibition or prostaglandin synthesis of COX-2. However, it does not have any effect on the COX-1 gene, thus decreasing the chance of adverse effects to the gastrointestinal and renal systems.

Although one may consider celecoxib in the treatment of OA, the drug also demonstrates the potential for side effects or complications associated with an increased risk of thrombus and/or subsequent cardiovascular events.4-6,9-11 In comparison to traditional NSAIDs, celecoxib has an increased risk because of the medication’s non-cardio protective benefit. Accordingly, the practitioner must err on the side of caution when prescribing celecoxib based on an individual’s overall medical and/or comorbid conditions.

Key Insights On Cortisone Injections And Viscosupplementation
Many practitioners utilize intraarticular cortisone therapies to help treat OA. Cortisone injections provide quick relief for a patient’s discomfort but the overall duration of pain relief varies depending upon an individual’s activity level or degree of OA. Cortisone therapy involves using a combination of a local anesthetic and a form of cortisone, which directly reduces an inflammatory process within the knee joint.

Cortisone is a form of corticosteroid that is available in many different forms. These forms include but are not limited to methylprednisolone acetate (Depo-Medrol®, Pfizer), triamcinolone acetonide (Kenalog®), triamcinolone hexacetonide (Aristospan®, Stiefel/Glades) and dexamethasone sodium phosphate (Decadron®). Each cortisone preparation exerts a slightly different effect but the overall goal is inhibition of the inflammation process within the knee joint. Although many different forms of cortisone are available for clinical use, the type and dosage tends to be based on the practitioner understanding of cortisone preparation, its dosage, benefit and side effects. However, a minimal recommended amount should include 1 mg/kg for large joints such as the knee, based on the cortisone choice and concentration.4,9,11,12

Viscosupplementation (or hyaluronic acid) has also emerged as an additional treatment for managing the symptoms of OA. Theoretically, viscosupplementation produces its effect by increasing the viscosity of the synovial fluid within the joint as opposed to focusing primarily on the inflammatory process.

Here is an AP weightbearing X-ray that demonstrates an OCD lesion and the medial femoral condyle.

In a healthy individual, hyaluronic acid is a normal fluid byproduct of synovial cells that helps lubricate and protect the joint. When people have OA, there may be reduced hyaluronic acid concentration and distribution due to its constant production. Accordingly, there would be a resulting decrease of viscosity and lubrication within the joint. Derived from rooster combs, viscosupplementation involves the injection of a synthetic hyaluronic acid. Viscosupplementation increases the concentration and/or viscosity of the synovial fluid, leading to a thickening of lubrication and a reduction of friction within the joint.

Currently, viscosupplementation is only FDA approved for the knee. Clinicians should reserve it as a second-line treatment for OA. There are various forms of hyaluronic acids including but not limited to Hyalgan (Sanofi-Aventis), Supartz (Smith and Nephew), Synvisc (Genzyme) and Orthovisc (Ortho Biotech). Since there is a variety of options available, the practitioner must follow the recommended amount of joint injections in order to maximize the overall benefit of these injections. Possible drawbacks to the use of hyaluronic acid include cost and patient compliance. Contraindications include advanced arthrosis. Extreme contraindications include an allergy to hyaluron, avian products, feathers, chickens or egg products, given the development of hyaluronic acid from rooster combs.2,4,5,10-12

A Few Thoughts On Physical Therapy And Bracing
Physical therapy is the gold standard not only in treating OA but many different orthopaedic disorders as well. When an individual undergoes a supervised physical therapy program, key points of emphasis are ensuring or maintaining range of motion and strength, and educating the patient on the importance of continuing the program at home. Maintaining range of motion is vital to ensure that one affected with OA does not develop a flexion and/or extension contracture, which would limit overall motion in the knee joint. Strengthening of the quadriceps mechanism with isometric and open and closed chain exercises helps maintain or restore stability of the knee joint, and the mechanical axis of the lower extremity.6

Bracing is an additive form of physical therapy that may offer a means of external support for a varus/valgus deformity during and/or after a supervised therapy program. An OA brace is a prescribed durable medical product that is available as either a customized or non-customized device based on the significance of the deformity and body habitus. One can obtain these braces from an individual who is certified in prosthetics. The brace is designed to unload an affected knee compartment in 2 to 3-degree increments based on the deformity. The goal is to alleviate friction between opposing articular surfaces during weightbearing activities. Although the brace is supported in the literature as a treatment option for OA, patient compliance is a factor due to the cost, fitting and appearance of the brace.

Does Nutrition Play A Role?
We were all taught about the importance of a well balanced diet to ensure a healthy lifestyle and reduce the risk of obesity, diabetes, coronary artery disease (CAD) and hypertension. The same is true for OA. A well balanced diet within the recommended daily allowances (RDA), including calcium and vitamin D, helps maintain a balanced homeostatic environment for the production of synovial fluid, the maintenance of bone structure to avoid collapse associated with osteoporosis, and/or avascular changes. Additionally, educating patients on the importance of a well balanced diet can prevent the onset of obesity, which increases sheer force and loading compression of the articular surfaces within the knee.

An Overview Of Surgical Treatment Options
There are surgical procedures that offer preventative or restorative benefit in treating OA. A preventative approach might consist of an athlete undergoing a knee arthroscopy for treatment of an acute injury to help restore the integrity and/or balance of the knee. Doing so might prevent earlier development of OA. Other examples of procedures that might help prevent earlier development of OA would include an ACL reconstruction, partial meniscectomy, meniscal repair, meniscal transplantation, fixation of a stable OCD lesion, or chondrocyte transplantation either via an autograft or allograft technique for an unstable OCD.
A restorative approach involves techniques to realign a deformity of the lower extremity for a varus/valgus deformity such as a high tibial osteotomy (HTO), unicondylar or total knee replacement. Although the following information will describe the latter techniques from a surgical perspective, an orthopaedic specialist bases the type of procedure on the individual’s examination and diagnosis.

Understanding The Benefits Of Arthroscopy
In the past, middle-aged athletes underwent a more invasive procedure such as an arthrotomy for the above procedures based on early instrument design. Today, the majority of outpatient knee procedures are completed via arthroscopy. Arthroscopy involves visualization within the knee joint with the aid of a camera through small incisions on the anterior aspect of the knee. With the use of small instrumentation, one can now treat athletic disorders through a minimally invasive approach. Accordingly, this less invasive approach results in less pain and facilitates a more focused post-operative physical therapy program.13

Should You Refer Patients For Meniscus Surgery?
Meniscus surgery involves partially removing, repairing or transplanting a previously excised meniscus to aid in the balance and prevention of a continued insult to the adjacent articular surfaces.

A partial meniscectomy involves debridement or recontouring a torn meniscus to a stable rim with the use of an intraarticular shaver. A surgeon can only accomplish a meniscal repair when the meniscal tear meets the criteria of a red-on-white, red-on-red or a tear within 3 to 4 mm of the meniscal capsular junction. These criteria ensure an active blood supply for healing because the meniscus itself is avascular.

The lateral X-ray above demonstrates an OCD lesion and its crescent-shaped appearance.

A new procedure, referred to as a meniscal transplant, involves transplanting a cadaver meniscus and anchoring it anterior and posterior to the aspect of the affected compartment. The goal or intention of the meniscal transplant is to offer support or a cushion between opposing arthritic surfaces while helping to restore balance to the knee joint and lower extremity.7,14 Although meniscal transplantation is a new technique to aid in treating selected disorders to the knee, it is a procedure performed by orthopaedic surgeons who have undergone advanced training, and is only indicated for a specific patient population.

When A Patient Presents With An OCD Lesion
Previously, I mentioned a lesion called an OCD as a potential etiological variable in the development of OA. An OCD is a lesion that has a crescent shape appearance. It derives from one or more ossification centers with sequential degeneration and/or aseptic necrosis and recalcification most commonly affecting the medial femoral condyle (MFC). One would best visualize this on a lateral knee X-ray or a MRI scan. These lesions may present in the juvenile or adult stages of life. Clinicians would classify these lesions as either stable or unstable, and they are normally confirmed by arthroscopic examination.

A stable OCD involves an intact articular surface and subchondral bone separation from the femoral condyle. The goal in treating a stable OCD is to try and fixate the lesion in its original position. An abrasion chondroplasty or microfracture technique, osteochondral drilling or fixation with absorbable pins or screws accomplishes potential healing of the lesion.

An unstable OCD involves subchondral bone separation and a disruption of the articular surface, causing the lesion to become displaced from the femoral condyle. One would surgically correct an unstable OCD via removal of the lesion, curettage of the underlying fibrous bed, and repair of the defect by various techniques such as fresh-frozen allografts, mosaicplasty autograft or chondrocyte transplantation.8,13,15,16
The use of fresh-frozen allografts involves transplanting an allograft specific to the diameter and shape after one has prepared the lesion bed by removing the diseased portion of the bone. Mosaicplasty autograft involves taking osteochondral plugs from the peripheral anterior medial/lateral portions of the femoral condyle and transplanting them to the affected area.

Chondrocyte transplantation is the new technique that involves the harvesting, culturing and subsequent placement of articular cartilage in the defect.13,15,16 With the cells present, the surgeon would then suture a periosteal flap over the defect. Regardless of the technique, one must emphasize a strict postoperative regimen to the patient in order to help ensure maximum benefit.

Can OA Patients Benefit From Other Minor Invasive Techniques?
Minimally invasive procedures for aiding the aging athlete with OA include techniques such as HTOs, unicondylar and total knee replacement. A high tibial osteotomy can help restore the mechanical axis or tibial femoral angle for a varus deformity. The technique involves removing a wedge of bone from the tibia, bringing the cut edges together, and fixating the osteotomy with a plate and screws. The goal of an HTO is to open the medial joint space and realign the lower extremity while unloading medial compartmental pressure during weightbearing activities. Surgeons may correct a valgus deformity by performing a distal femoral osteotomy and unloading the lateral compartment similar to the aforementioned procedure. Although the latter procedures have been beneficial, surgeons usually reserve them for a specific population if other treatment options are not beneficial.

Here one can see a unicondylar knee replacement.

Knee replacement surgery may be unicondylar in nature or involve the entire knee joint for a total knee replacement. Today, technology has not only improved implant longevity but there have also been advances in the design of instruments for performing the indicated replacement through a minimally invasive approach. A unicondylar replacement involves replacing the arthritic compartment with a metal femoral and tibial component, and a polyethylene spacer to balance and stabilize the knee joint. This procedure may be an option after all conservative treatment has been exhausted. A total knee replacement involves replacing all three compartments yet through a smaller incision than surgeons utilized previously.

Final Notes
Indeed, there are a variety of treatment options for the aging athlete with OA. Recent advances have expanded the options in the armamentarium and have improved upon previously utilized treatment approaches in some areas. Of course, ensuring a detailed patient history, physical and diagnostic evaluation is essential prior to deciding upon a mutually agreed upon treatment regimen.