arthroscopic knee surgery

Steroid shots and arthroscopic surgery have been mainstays in the treatment of pain and inflammation brought on by knee arthritis. Many people try to delay knee replacement as long as possible, especially if they are relatively young. But new research suggests that steroid injections provide little, if any, benefits and may cause harm. New guidelines from a group of international experts is equally negative when it comes to arthroscopic knee surgery (BMJ, May 10, 2017).

Why Patients Get Steroid Shots and Surgery:

It is estimated that one out of four patients over 50 years of age has knee pain linked to osteoarthritis. Degeneration of cartilage in the knee not only hurts but can curtail activities. It is hard to hike, dance or move around when your knees ache. Knee replacement is usually a last resort. That means that health professionals often offer other options first.

Doctors like to pride themselves on practicing “evidence based medicine.” That means they often reject so-called alternative treatments that remain unproven. But what if standard medical treatments themselves are ineffective or even counterproductive?

Recommendations from Experts:

Many patients turn to nonprofit organizations like the Arthritis Foundation in the hopes of getting sound, objective recommendations. Here is what the Arthritis Foundation states on its website about these treatment strategies:

Corticosteroid injections: “Injecting corticosteroid compounds directly into affected joints can be useful for decreasing pain in the short term, although the effect tends to wear off after a few weeks. To maintain relief, you may need to have corticosteroid injections in the same joint every few months, or use another treatment.”

Knee Surgery: “When pain is not helped by other treatments, many people find knee surgery an option well worth pursuing…

Arthroscopy is a minimally invasive knee surgery performed by inserting a lighted scope and narrow instruments through small incisions in the skin over the knee. Arthroscopic surgery can be used for the following:
• to remove or repair torn menisci
• to repair a torn cruciate ligament
• to trim torn pieces of joint cartilage
• to remove loose bodies
• to remove an inflamed joint lining (synovectomy).

While knee arthroscopy is a procedure that is helpful for many people, there is controversy over the usefulness of some arthroscopic procedures.”

We Offer a Different Perspective:

The New Research on Corticosteroid Shots:

Here is the latest update on steroid shots into the knee:

“Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis.” JAMA, May 16, 2017.

Osteoarthritis of the knee is at its core a condition of inflammation. The researchers writing in JAMA note that:

“Clinical and epidemiological studies found that inflammation is common in the knee joints of people with knee osteoarthritis and associated with progression of cartilage damage. These observations suggest that suppression of inflammatory processes by corticosteroids (already in widespread clinical use for knee osteoarthritis) might reduce progression of knee osteoarthritis.”

The researchers quickly caution, though, that such steroid shots into the knee joint have been associated with “adverse joint outcomes” and “have raised questions about their potential to damage joints.”

That is why these scientists undertook a two-year clinical trial to test the benefits and harms of such treatment. What they found represents a cautionary tale for any health professional who offers steroid shots to patients with knee arthritis.

What They Did:

The investigators recruited 140 patients with painful knee arthritis. Half were given shots of the corticosteroid triamcinolone every three months for two years. The other half received placebo shots of saline [salt water]. Neither the health professionals nor the patients knew who got what.

What They Found:

Contrary to popular belief, the steroid shots did not reduce knee pain any better than saline injections. There was, however, “greater cartilage volume loss.” That is not a good thing. In their own words the authors write:

“The use of MRI in this study enabled direct quantitation of cartilage and soft-tissue structures and showed more cartilage loss in the triamcinolone group than in the saline group.”

In other words, steroid injections provided no noticeable benefit and a certain amount of risk.

Their conclusions:

“These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”

Arthroscopic Surgery for Knee Arthritis:

An arthroscope is a instrument with a tiny camera at the end. An orthopedic surgeon inserts this device into the knee. It allows the doctor to see problems like a torn meniscus or pieces of cartilage that have come loose inside the knee. Very small instruments can then repair tears or remove torn cartilage.

According to experts writing in the BMJ (May 10, 2017), arthroscopic knee surgery “costs more than $3 billion per year in the U.S. alone.” Are people getting their money’s worth?

The panel of experts who wrote the new guidelines analyzed data from 13 randomized trials and 12 observational studies. They were particularly interested in “pain, function and quality of life.”

What They Found:

“The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long term pain or function. Most patients will experience an important improvement in pain and function without arthroscopy.”

The lead author and chair of the guideline panel, Reed Siemieniuk, MD, told Reuters Health:

“It does more harm than good. Most patients experience improvement after arthroscopy, but in many cases, this is probably wrongly attributed to the surgery itself rather than to the natural course of the disease, a placebo effect, or (other) interventions like painkillers and exercise.”

Complications can include pain, swelling, infection or blood clot formation.

Dr. Siemieniuk went on to tell Reuters:

“We believe that no one or almost no one would want this surgery if they understood the evidence.”

What Can People with Knee Arthritis Do?

Millions of people suffer from knee arthritis. Just walking can be painful. Jogging, playing tennis or golf may be out of the question. Short of knee replacement surgery, there are not a lot of medical options.

Over the last several years we have learned about serious or even deadly side effects from NSAIDs (non steroidal anti-inflammatory drugs). Celecoxib, diclofenac, ibuprofen, meloxicam and naproxen have been linked to a surprisingly long list of worrisome adverse reactions. They include:

  • Stomach ulcers
  • Heart attacks
  • Strokes
  • Atrial fibrillation
  • Heart failure
  • Hypertension
  • Kidney damage
  • Liver damage

Learn more about the benefits and risks of NSAIDs at this link:

Really Bad News About Ibuprofen, Naproxen and Other NSAIDs

Now we learn that corticosteroid injections into the knee joint may damage cartilage and produce little, if any, benefit. And surgery for knee arthritis offers modest, if any, help.

Topical NSAIDs vs Oral NSAIDs:

There is some reason to believe that topical NSAIDs may be less troublesome than oral medicines. You can read more about this approach at this link:

Can You Avoid NSAID Danger with Topical Pain Relievers?

Non-Drug Alternatives for Knee Arthritis:

Many physicians pooh-pooh non-drug approaches in general. They bemoan the lack of evidence. That, despite data now demonstrating that traditional medical practices for knee arthritis are either ineffective or harmful.

If you would like to learn more about a range of options you might find our interview with arthritis specialist, Beth Jonas, MD, enlightening. She is open minded and offers a number of practical suggestions. You can listen for free at this link:

Show 1076: Finding New Ways to Ease Joint Pain

In addition, we have prepared a 54-page online resource titled “Alternatives for Arthritis.” In it we discuss in greater detail topical NSAIDs as well as several home remedies:

  • Tart Cherries
  • The Gin-Raisin Remedy
  • Certo and Grape Juice
  • Knox Gelatin
  • Vinegar and Juice
  • Pineapple (bromelain)

Plus, herbs and spices like Ashwagandha, boswelia, turmeric, ginger and stinging nettle.

You will also learn about apitherapy and acupuncture.

Here is a link:

Share your own experience with knee arthritis below in the comment section. If you found this information helpful, please vote at the top of the article.

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  1. George
    South Padre Island Texas
    Reply

    An ortho told me I to get a knee replacement. I ignored him because it wasn’t that bad. Another renowned ortho who is a friend told me that the actual need for replacement is rare. Most are unnecessary. He also has osteoarthritis and is 75. We were on a vigorous hiking trip in Scotland. I have found that glucosamine with mom, zyflamend, and using a copper fit or Tommie copper knee sleeve helps. Copper fit is cheaper. My knee is better now than it was 10 yrs ago.

  2. Jeff
    TX
    Reply

    Why not use bone broth as an adjunct therapy?

  3. Margaret
    Charlotte, NC
    Reply

    I count on the Peoples Pharmacy for the best medical information, but I have to disagree about not having arthroscopic knee surgery. I have had torn meniscus in both knees. One was repaired over 10 years ago, and the other in the past year. The first knee was painful, but the second knee was so painful that there was no way I could have gone without surgical repair, as a torn flap of the meniscus had dropped down into the joint. I am so grateful to be able to garden and walk again, and be an active 70 year old. Also, I have many friends who have had knee replacement surgery that has given them a new lease on life. I do thank you and your show for bringing the dangers of the NSAIDs to our attention, as it is probably too easy to reach for them when something aches. I am finding a hot shower and some analgesic cream go a long way!
    Thank you for all you do to keep us safe and healthy!

  4. Torrence
    Boardman Ohio
    Reply

    A couple of things. There are many different kind of shots you can get in your knee. I have been getting them for years with NO side effects. Make sure the doctor you go to is a specialist. Also, I found out that if you DO get the operation for knee replacement, the experts say to try and save as much of the knee as possible. The outcome will be MUCH better that way. Check it out for yourself!!!!!!!!!!

  5. Helen M.
    Modesto
    Reply

    I don’t think replacement knee surgery is for everyone. You have to have realistic expectations in order to consider it successful. Less pain than before the surgery? Ck. Less stiffness in the joint? Ck. Still some pain, especially at night? Ck. I have had my right knee replaced, and my husband had both done. He could not go back to work as an electrician; however, he has been able to pick up gardening as his retirement hobby and has been good at it. He also does all the maintenance inside and outside, plus helps several others when they have problems. He can work for several hours, but not for a whole day: the continuing pain in his knees prevents that. I can use that leg to go up and down stairs, whereas I could not before the surgery. Hubby did not have a great deal of pain after his surgeries, six months apart. I have another bad knee that I will not have done because I remember the pain of recovery all too well.

    I defied all odds and recovered much better than either the surgeon or the therapist thought I would. But they gave their all, and I gave mine. I was darned if I was going to go thru all that pain to a small, if non existent, reward. Nope, I did my best for a good recovery, and it was. Nevertheless, my other knee does not hurt as badly as the first one did, so no surgery for it.

  6. Carol
    Allen tx
    Reply

    I was about to have injections in my knee but tried msm. I haven’t had any knee pain in three weeks.

  7. Paul
    New Hampshire
    Reply

    Recently I saw your blog on Pyridoxine and nerve pain. I went to the reference you cited in Pub Med and read the article. Very eye opening. Furthermore there were other references describing the same side effect. Both my wife and I have been taking B Vitamins including Pyridoxine for several years. Recently I increased the dose from 25mg to 50mg. I have had some problems with Statins in the past with neuropathy but she seemed “bulletproof” to arthritis or nerve pains and then suddenly she started complaining about leg pains and stiffness. After reading the article we both stopped the pyridoxine and after a few days my wife is doing much better and so am I. You are right. Sometimes more is not better. Thanks for being there.

  8. sura
    Dallas
    Reply

    I have found steroid shots in the knees have been very helpful, especially before travel with a lot of walking. Have also had Effluxxa shots, which have been helpful as well. I try to avoid knee replacement as long as I can, since they come up with better ones all the time. I also use a brace when I dance. Glucosamine/chondroitin/MSM taken orally made a big difference. When I stopped it, terrible pain came back, so I went on it again.

  9. Joseph Marovich
    OH
    Reply

    I’m very surprised that there was no mention in this fine article about precise injections into the knee joint. I’ve had osteo-arthritis in my left knee for over 30 years after completely tearing my anterior cruciate ligament at the age of 39. I have lived with it for many years until it became very painful in 2013. I had read about injections of Hyalgan in an ad in the newspaper.

    After consulting with my primary care physician, who was skeptical, he said if there’s an M.D. involved there was certainly no harm in trying. Although the treatment was in a Chiropractic pratice, the treatment was under the supervision of an M.D. In January of 2014 I had my first of 5 weekly injections. By the 3rd injection, there was no pain at all. The only discomfort I now have is when carrying something somewhat heavy up the stairs. Regular walking is fine, but my primary said no running. Not everyone has my success; in fact, I was told that many who have the treatment go back for the same treatment in 5-6 months. It was completely covered by Medicare.

  10. Steve
    Raleigh NC
    Reply

    I am 74, My knee pain was so constant, it was almost all I could think about. Normal walking was impossible. The pain often woke me up from my sleep. My doctor diagnosed the condition as osteoarthritis and for all the reasons mentioned in the above studies offered little in the way of relief. On the advice of a friend, I started taking 1500 mg of turmeric twice daily. Within three days I was pain free. It was remarkable.

    A year has passed since I started this treatment and I have only experienced mild episodes of pain, usually after a long walk.

  11. Ralph
    Missouri
    Reply

    I agree with the article. I had two cortisone injections in my knee. It only helped alleviate pain for about a month. I was told you shouldn’t have more than 3 cortizone injections in a joint by some PT a few years ago. I also utilized a variety of over the counter meds, as well as topical creams. But it got to the point that nothing was helping. The miniscus was completely worn away, I had three bone spurs, my ACL was gone and my knee was bone on bone. All the result of an injury incurred in the military and misdiagnosed at the time it occurred several decades ago. Just had a total knee replacement, so far so good. I’ll know more in a year or so.

  12. Kristin
    AZ
    Reply

    I had bad knees for decades after being a ski racer in my 20s. In my 50s I developed horrible sciatica because my knees were so eroded that I was getting very bow-legged (the change in my knees caused my femurs to fit into my hips differently and press on my sciatic nerves). Before the insurance co. would let me get knee replacements, they required many epidural injections, knee braces, physical therapy, and many other things. Nothing helped at all. Two years ago i had both knees replaced. It was the best things I’ve ever done for myself. I can now easily hike 8-10 miles over hilly, rough terrain with zero pain and no swelling in my knees. My sciatica is completely GONE because my legs are again straight. Recovery from knee surgery wasn’t bad at all, mainly because I got as strong as I could BEFORE I had the surgeries.

  13. Marilee
    Reply

    Obviously, everyone is probably different, but several years ago I suffered a knee-ripping injury that required immediate attention. The orthopedic specialist said, after tests, that I had a combination of osteo-arthritis and a torn meniscus. He recommended arthroscopic knee surgery. I demurred, wondering if healing rest and physical therapy [he had mentioned these dismissively in passing] might not be worth trying. He said he didn’t think so, but of course, I could try if I insisted, as he was sure I’d being coming back wanting the surgery, which could be done later, when I recognized he “was right”. He gave me two prescriptions, a week’s worth of steroids and one for PT.

    I went to one of the recommended PT office a week later, when I could hobble using a cane. My knee still hurt like the devil, but the swelling was down. The PT office did their own careful testing of my knee, looking at the MRI too, from a physical point of view, and I was told they thought I was a good candidate for PT and would I like to start right now? I said sure. They used some kind of sound/vibration device, gentle massage, strength and flexibility exercises, using the stationary bike, three times a week over the next month. By the end of my sessions I was completely pain-free and fully mobile. I remain so today, years later, without surgery, without steroid shots, without complications. I can’t even remember which knee had “needed” surgery. You don’t recommend PT in this article for knee issues, but I am a believer.

    On a related note, my husband had terrible Sciatica plaguing his legs for 4 or 5 months. Nothing helped, including meds, spinal area injections, massage, seeing several doctors including a neurologist, orthopedist and spine specialist … until, on recommendation of an acquaintance who’d been helped, he went to a skilled PT practioner who gave him some very specific, unusual Australian-origin exercises that he said should work, only requiring 4 or 5 clinic sessions plus at home exercises. In two weeks the pain my husband had suffered for so long was gone. To their credit, the neurologist and spine doctor were extremely interested and are exploring the possibilities of this therapeutic treatment for sciatica. His orthopedist was not interested in learning more.

    One can’t help but wonder why orthopedists are so focused on cutting, when there are non-invasive alternatives to try before surgery.

  14. Kat
    Florida
    Reply

    I had arthroscopic knee surgery in 2003 for torn meniscus, bone spurs and bone chips that were floating around my knee area. I had immediate relief of pain, and could walk and excercise again. It’s been 14 years since the earlier surgery (I’m now 68), but I’ve gone longer than my first ortho thought I would before needing replacement, so I’m a happy camper. The knee hasn’t always been great, but just recently (within the last year) it’s started to hurt more when I’m standing for any length of time (while cooking, etc). The cartilage is gone, so it’s time for knee replacement.

  15. Joan
    St Louis
    Reply

    I use to get the shots for my arthritis in my knee (3 years ago my last shot) I read a comment on your column about a gentleman 70,s that tried Hyaluronic Acid pills with success
    I’ve been taking 1 a day for 3 years No Pain I use the Solgar Brand 120 Mg & buy them online I still ache with arthritis but my knee hasn’t given out & my knee pain is gone I also take 1 Aleve a day but always have after prescribed by a orthopedic Dr 15 yrs ago

  16. Diane
    Kansas City
    Reply

    Was just told yesterday about “Tumeric” by a young woman who said she and her grandfather had both had success with it. She recommended from Whole Foods or Natural Grocers as opposed to drug or grocery store pharmacy.

  17. SJ
    Co
    Reply

    It would be nice to read more about Stem Cell Therapy to repair joints. I have talked with a few people who have had this done and they are very pleased with the results. In depth information from you would be eye opening for millions of people.

  18. Bruce H
    Houston
    Reply

    Your might want to try Penetrex ointment in combination with Curamed Curcumin capsules before you go down these other roads. It has helped me.

  19. Patti
    FL
    Reply

    After my first experience with knee swelling/pain I had one corticosteroid injection. It resolved my problem and I had twelve years without a recurrance. Two years ago I needed another and so far so good. I’m 74.

  20. joyce
    durham nc
    Reply

    Please go ahead and have your knee replaced!! Find a surgeon that only does knees and schedule a visit. I was on meloxicam for 3 years first and now I have tinnitus and tremors, both possible side effects from prolonged nsaid use. My surgery was a big deal, but it was much easier and pain-free than I expected and I LOVE my new knee, I can do anything I want now and the freedom is exhilarating! Just DO IT!

    • JP Saleeby, MD
      Carolinas
      Reply

      Surgery is surgery with all the risks associated. I would beg to differ to jumping right in and having an operation. Oh, and those knees don’t last forever, expect to have it revised (replaced) eventually. Also they are not risk free… some issues with chromium and other alloy toxicities have occurred in some of my patients who had joint replacements, requiring the old joint to come out and a new one to replace it….thus two surgeries and also the toxic effects of those metals on their kidney function. Do more research before jumping into the surgery arena.

  21. Mark
    Dallas
    Reply

    I experienced difficulty walking, especially going down stairs, and 2 surgeons from different offices told me I needed surgery for a torn meniscus. I began taking turmeric capsules and started exercises to strengthen the muscles around the knee. I didn’t come up with this on my own, I read a couple articles and had watched a short video on which exercises to do.

    They are very simple exercises you do at home and take maybe 5 minutes to complete. I experienced relief in a very short amount of time and am able to jog now. I no longer have problems with knee pain. I have shared this information with several people who have had the same results. That was a couple of years ago and I still do not have any knee pain.

  22. Marsha
    Orlando fl
    Reply

    I was disappointed that your article on knee pain did not include any reference to hyalgan injections or stem cell therapy. I had knee pain for 14 years and got relief from hyalgan injections for 10 years. I went for the series of 3 every 9 months to a year. In 2016 I had stem cell injections. It worked so well in my right knee that I did the left as soon as the doctor allowed me to. I haven’t needed the hyalgan or anything else for knee pain since. The only down side of my experience was I had to pay for it myself.

  23. Craig
    Newtown PA
    Reply

    I blew my right knee out playing football in 1982. I have no acl and my knee rotated at a 90% angle laterally. I did not have any surgery. I was in a knee mobilizer for 3 months. 12 years later my knee started to lock up when i walked down the street so I had arthroscope surgery in 1994. I had a local, I was not put out and watched the surgery on a screen while the Dr told me what he was doing. It was great. I can fully squat, single leg pistol, etc. I tore my left knee in 1996 during a BJJ competition. I just had arthroscope surgery yesterday 5/18/17 because the tear has gotten worse. This time they put me under. It has been 24 hours since the surgery, I have no pain at all, just some muscle soreness near the top of the knee. I have not taken any pain meds at all, nor do I plan to. I can walk up and down stairs but I can’t fully bend my knee yet, only about 45 degrees.

    I am active, I train 7 days a week from joint mobility, to Kettlebells, to Roping, to Club bells to many different forms of Qigong and meditation both qigoing and TM. I agree with what you are saying about steroid injections, I never had one and I would never get one. I also do not take any pain killers. I use mag oil topically on both knees, Turmeric pills and in my drink, and take orally organic sulfur with MSM. I use to take DMSO years ago as well as condroition/congloseimeim (not spelled correctly) but replaced them with the mag oil and sulfur. They work much better for me. I take them daily.

    I needed the surgery or the tears would have only gotten worse and eventually my knee could have locked up. The surgery might not be for everyone but for me it was the right thing to do.

  24. Joyce
    Reply

    Exercise

  25. Sue
    Florida
    Reply

    You did speak on the other treatment, Euflexa injections (sp). It is a series of three injections given over three consecutive weeks. It is a gel that adds extra cushioning and lubrication. The series lasts about 6 months. However, not all docs provide the choice and most require insurance that covers them (mine does) or money up front. My Rheumatologist has been giving them to me for about 3 years. This is another good option to add to your list. The only side effect I’ve had is just a slight soreness at the injection site.

    Another thing you did not discuss was exercise. I’ve found that doing specific weight bearing exercises at the gym helped a great deal. Strengthening the muscles that surround the knees give them more stability resulting in less pain. Get with a trainer if you have that available. Learn to do dead lifts with weights. Start low and build up weight over time. There are other options a trainer can demonstrate. It is worth every cent, there are no side effects, and you’ll feel better.

  26. Annie
    NZ
    Reply

    I do not agree with the evidence that steroid injection into the knee joint is not useful.

    In May 2015 my knee (already moderately painful) became much worse. As I was planning to walk Camino de Santiago in August/September that year it was a worry.

    I was referred to an orthopaedic specialist who put a steroid injection into the joint which gave considerable relief after one week. Not only did I complete the Camino in 31 days but even now 2 years later I am still very active. I realise it won’t last forever but for me it was an excellent result.

    I am 72 years old. My verdict: Try it and it might just delay the necessity for knee replacement.

  27. Tom
    Sarasota, Florida
    Reply

    Chronic knee problems for the past 10 years, have had arthroscopic surgery and injections, both providing temporary improvement. Now take one capsule of Move Free Ultra each day in addition to fresh pineapple juice and tart cherry juice concentrate.
    After 3 months, am pain free with no joint swelling!

  28. KAYE
    Westchester, il
    Reply

    YOU DO NOT MENTION SYN-VISC. IT REALLY HELPS ME. I AM BONE ON BONE IN ONE KNEE.

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