Nonsurgical treatments for knees and hips

Whether it's your hip or your knee that's bothering you, your doctor is likely to recommend the least invasive treatment to alleviate pain and encourage healing of your condition before resorting to surgery. Reducing inflammation, relieving pain, protecting the joint from further damage, and building strength in the muscles that support the joint can often improve joint function. The following treatments are often recommended for hip or knee pain and discomfort.

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RICE

RICE — which stands for rest, ice, compression, and elevation — is a first-aid strategy for most musculoskeletal injuries, including those involving the knees and hips. It is sometimes the only treatment you need.

Rest. Continuing to put stress on a painful injury can make it worse. Injuries need rest in order to heal. Rest doesn't always mean inactivity, however. Depending on the condition, you may need to stay off a leg entirely, cut back the distance you can run or walk without pain, switch to low-impact activities, or exercise using other parts of the body. It's important to rest an injury or flare-up of pain for a few days, but long periods of inactivity can make ongoing knee and hip problems worse by decreasing flexibility and weakening the muscles that support and protect the joints.

Ice. Cold numbs pain and reduces swelling by constricting blood vessels. After surgery or injury, wrap an ice pack in a cloth and apply for 20 minutes, remove for 20 minutes, apply for 20 minutes, and so on. To prevent frostbite, do not apply ice directly to the skin. Your source for cold can be as simple as a bag of frozen peas wrapped in a towel, but you can also buy easy-to-secure neoprene wraps with pockets for gel packs that you keep in the freezer. Most elaborate are electric "continuous-flow cold therapy" devices that deliver cold through pads shaped for different joints; your doctor or physical therapist may recommend such a device after surgery.

Ice helps knee injuries of all types. For hip injuries, cold can't penetrate deep into the hip joint itself, but it is still effective for hip pain stemming from problems closer to the surface, such as trochanteric bursitis.

After injury, use ice alone for 24–48 hours. After that, you can continue using ice, switch to heat, or alternate. Ice increases stiffness; you may find it beneficial to use warmth before stretching and other exercise, following with ice afterward to minimize swelling. You can give yourself an ice rub by freezing water in a paper cup. Peel back the paper a little so you can apply the ice while holding the paper covering.

Compression. After a knee injury, gentle pressure can reduce swelling and hasten recovery time. Wrap an injured joint in an elastic bandage, taking care that the wrap isn't so tight that the skin below the joint becomes cool or blue. Neoprene stretch knee supports provide compression and have a hole for the kneecap to prevent irritation.

Elevation. Elevating the injured area takes advantage of gravity to reduce the swelling and painful throbbing that occurs when lots of blood pools in the area. Prop your knee up on a stool with pillows to raise the height, or lie down with your knee on a pillow.

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Heat

Heat is a good way to reduce pain and stiffness in your joints and relieve muscle spasms. After an injury, wait a day or two for swelling to go down before using heat.

You can use a heat pack applied directly to the joint, or warm your knees and hips in a hot tub or whirlpool or with a 15- to 20-minute soak in a regular bath. Therapists recommend a warm shower or bath before exercising to relax joints and muscles. Dress warmly afterward to prolong the benefit. Heating pads are convenient, but moist heat penetrates deeper.

You can buy hot packs and moist-dry heating pads, but a homemade hot pack works just as well. Heat a damp folded towel in a microwave oven (usually for about 10–60 seconds, depending on the oven and the towel's thickness) or in a conventional oven set at 300° F (for about 5–10 minutes).

To relieve muscle spasms, a physical therapist may use diathermy (deep heat), a technique that uses electromagnetic waves to deliver heat beneath the skin and to relax muscles. Electromagnetic waves cannot be used on people with pacemakers.

Cold and heat work well in combination. You may benefit from using heat early in the morning and before exercise and using cold after exercise and at the end of the day.

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Ultrasound, phonophoresis, and iontophoresis

Therapeutic ultrasound uses sound waves to reach deep tissues in order to increase blood flow, relax muscle spasms, and aid healing. To do an ultrasound, the technician applies a gel to your skin and rubs an ultrasound wand over the area. In a technique called phonophoresis, medication (often hydrocortisone) is added to the gel and the ultrasound transducer applied over it. Because the ultrasound encourages blood vessels to expand, this approach is thought to deliver more medication to the injured area.

Another technique, iontophoresis, uses electrical currents to speed the delivery of medication to the damaged tissue, or simply to reduce muscle spasms and irritation from muscle spasms. Patches similar to Band-Aids are placed on the skin, and a painless, low-level current is applied for about 10–15 minutes. You may feel warmth or tingling during the treatment.

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Therapeutic exercise

Exercise is more than just a good health habit; it's also a specific and effective treatment for many knee and hip problems. Strength in the muscles around a damaged knee or hip can take over some of the joint's responsibilities. For example, your hips have to do less work to support your body weight if your quadriceps, gluteals, hamstrings, and abdominal muscles are stronger. Strong quadriceps can take over the shock-absorbing role usually played by the meniscus or cartilage in the knee. The proper balance of strength in the muscles can hold the joint in the most functional and least painful position. With any knee or hip problem, the first muscles to lose strength are the largest antigravity muscles, the quadriceps and gluteals, so an exercise plan for any injury is likely to focus on these.

Muscles work in pairs — one contracts while the opposing one relaxes. For example, when you straighten your knee, your quadriceps on the front of your thigh work, and the hamstrings on the back relax. Imbalances in the function of paired muscles can cause joint problems and invite injury. If your hamstrings are tight, your quadriceps can't contract fully and may weaken, so exercise the quadriceps and hamstrings (the opposing muscles) equally. Flexibility exercises (to stretch and relax specific muscles) are an important part of an exercise plan to improve joint function.

Closed-chain exercising. Physical therapists have emphasized the distinction between open-chain and closed-chain exercises. The chain referred to is a series of body parts, such as a hip, knee, ankle, and foot. In a closed-chain exercise, the part farthest from the body is stationary; in an open-chain exercise, it moves. For example, a squat is a closed-chain exercise because your feet stay stationary while your quadriceps do the work. In contrast, a seated leg extension is an open-chain maneuver. Physical therapists are incorporating more closed-chain exercises into rehab programs and recommending them for people with painful joints because these exercises involve more muscles and joints and help to create stability around a joint. Try a wall sit to strengthen your quadriceps, a crucial muscle in maintaining knee stability. Stand with your back against the wall, with your feet together, and slide down into a sitting position (see Figure 3). If you go to a gym with a leg press machine, you can use it for another type of closed-chain quadriceps exercise. When doing knee exercises that involve weight, avoid locking your knees or, conversely, lifting weight with your knee bent all the way.

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Exercising with a physical therapist

Physical therapy is often part of treatment for arthritis and other joint problems. A physical therapist individualizes your treatment program to restore or maintain your physical functioning and carries out specific instructions from your orthopedist.

First, the therapist thoroughly evaluates your pain, functional ability, strength, and endurance. A physical therapy session may involve pain-relieving treatments using ice, heat, massage, or other approaches. The physical therapist supervises you in doing exercises and teaches you exercises you can do at home. Depending on the therapy center, there may be a pool and a variety of exercise equipment to use.

Gait retraining. Knee and hip problems can disrupt your normal walk by causing pain, restricting joint movement, or weakening muscles. A person's usual pattern of standing, walking, or running may also invite joint problems if weakness in key muscles, poor coaching advice, or bad habits throw off the gait. It may take many years of walking with an abnormal gait before joint injury occurs. Improper running leads to pain and injury more rapidly because it involves greater force with each stride.

A physical therapist analyzes your gait and helps you learn to walk more normally. Initially, the proper gait may feel odd; you will most likely need practice and continued instruction before it becomes comfortable. The physical therapist may suggest a change in shoes or specific exercises to strengthen muscles you may be trying to avoid using.

If you have had a knee or hip replacement, gait retraining helps you relearn to stand up straight (the tendency is to lean toward your operated leg) and use both legs evenly. Gait retraining may begin in the pool, where the water's buoyancy takes weight off the joint, makes it easier to stand up straight, and reduces the fear of falling.

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Medication

Several types of medication are used for knee and hip problems, some to control pain and inflammation and others to interfere with various disease processes (see Table 1).

Acetaminophen. For pain relief, acetaminophen (Tylenol) is generally the first choice because it is effective and easy on the stomach. Do not exceed the recommended dosage of acetaminophen, however, because it can damage the liver.

NSAIDs. Nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox), and several others may be more effective than acetaminophen, particularly during sudden flare-ups of pain, because they are superior at reducing inflammation. There are also a number of prescription NSAIDs such as nabumetone (Relafin) and oxaprozin (Daypro).

But this relief comes at a price. Regular use of NSAIDs can produce gastrointestinal bleeding and ulcers, often without warning. Each year, these drugs contribute to more than 16,500 deaths and 100,000 hospitalizations because of gastric bleeding. Combining acetaminophen with a smaller amount of an NSAID may provide equivalent pain relief with a reduction in side effects.

The class of prescription NSAIDs known as COX-2 inhibitors is now rarely used, following news in 2004 that these drugs significantly increase a person's risk of heart attack and stroke. The manufacturers of two popular COX-2 inhibitors, rofecoxib (Vioxx) and valdecoxib (Bextra), withdrew these drugs from the market. A third COX-2 inhibitor, celecoxib (Celebrex), remains available. Because concerns about its cardiovascular side effects remain, it should be used only in cases in which a patient does not have heart disease, has tried other pain relievers without success, and is taking blood thinners (anticoagulants such as warfarin).

Opioids. Another large class of pain-relieving drugs are the opioid medications such as codeine and oxycodone, which have morphine-like properties. The term opioid has, by and large, supplanted "narcotic" as the preferred term for these drugs because the latter term has legal and regulatory meanings. Opioids work by interacting with the receptors on brain and spinal cord nerves for the endogenous opioids, which are the body's natural painkilling substances. For orthopedic problems such as knee and hip conditions, opioids are used judiciously, often for only brief periods just before and after surgery, or in patients with severe pain who are not helped by or are unable to tolerate NSAIDs. Opioids are effective in masking pain but do not help inflammation. Care must be taken to avoid tolerance, which develops after just two weeks, and side effects such as dizziness can make it difficult for people to participate in physical therapy while taking these medications.

Corticosteroids. Corticosteroids, such as prednisone, reduce the body's ability to generate an inflammatory reaction. They relieve pain by reducing inflammation. Corticosteroids are credited with both treating and causing knee and hip problems. When first introduced in the 1950s, corticosteroids were regarded as miracle drugs because of the dramatic effect on patients with active rheumatoid arthritis, many of whom were able to literally throw down their crutches. But within a few years, the devastating effects of long-term use of oral corticosteroids became apparent: bone weakening, compression fractures of the back, diabetes, increased susceptibility to infections, cataracts, hypertension, and other health problems. Most side effects occur when these drugs are taken orally, but repeated corticosteroid injections into a joint can result in thinning of the cartilage and weakening of the ligaments. In the short-term, though, corticosteroids can sometimes provide quick and dramatic relief.

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Alternative approaches

Over the years, people have turned to a wide variety of remedies to cope with the frustrating problem of joint pain. The choices are many because joint pain has been around for many centuries and nearly every traditional culture has developed medicines or therapies to treat it. Many of these remedies lack scientific support. But so long as they are not harmful, there is no reason not to use traditional or complementary therapies that seem to bring you relief. A few complementary therapies have some demonstrated effectiveness.

Acupuncture. This ancient Chinese technique uses slim needles to stimulate points along the body's "energy meridians" to correct disease-causing imbalances. In the language of Western medicine, acupuncture may work by releasing endorphins, natural morphine-like chemicals in the nervous system.

In 1997, a National Institutes of Health consensus panel concluded that acupuncture is an acceptable alternative or adjunct for treating many kinds of pain, including that from osteoarthritis. Since then, a number of studies have offered positive results specific to knees and hips. A 1999 study indicated that acupuncture may also be useful in patellofemoral pain syndrome, and a small trial in 2001 looking at people with hip osteoarthritis showed that acupuncture helped them more than exercise did. A large 2004 study found that people with knee osteoarthritis who had acupuncture for six months reported less pain and better function than people who received sham acupuncture or participated in an arthritis education program.

Glucosamine and chondroitin sulfate. Glucosamine is a substance normally found in both cartilage and synovial fluid, and chondroitin sulfate is one component of a protein that makes cartilage elastic. It isn't clear how supplements of these nutrients might work, but it's possible that they may encourage cartilage formation and minimize further breakdown while also reducing inflammation. Some skeptics compare this theory to that of a balding person eating hair in the hopes that it will grow on his head. At the same time, some patients swear these supplements provide genuine improvements.

So far, research on these supplements' effectiveness has offered mixed results. A large 2006 study published in the New England Journal of Medicine concluded that glucosamine and chondroitin did not reduce pain effectively over all, but that the supplements did benefit a subgroup of patients with moderate to severe pain. Two earlier three-year studies in Europe found that people with knee osteoarthritis taking glucosamine had significantly less pain and narrowing of their joint space than those taking a placebo. Chondroitin sulfate seemed to decrease pain in a three-month trial.

Common side effects include intestinal gas and softened stools. Chondroitin sulfate structurally resembles the anti-clotting drug heparin; if you're taking blood-thinning medication, tell your doctor and monitor your blood-clotting time. Because glucosamine may worsen diabetes, watch blood sugar levels carefully. Glucosamine is manufactured from chitin found in the shells of crustaceans, so people with shellfish allergies may react to it. In addition, studies show that the amount of glucosamine present in the products available in stores varies widely among manufacturers and possibly from batch to batch within the same brand, so it's difficult to know how much you're getting when you use this product.

Over all, these supplements appear safe but there is still no consensus on their effectiveness. If your pain has not responded to other treatments, feel free to give them a try. Treatment usually costs a dollar a day or more, so prolonged therapy is probably not warranted if it doesn't seem to help in two or three months.

People with joint pain need to educate themselves and become wise consumers. Don't buy into any treatment that promises a cure. Think instead of managing your condition. There are many complementary therapies to choose from, some of which may have interactions with medications you may be taking. That means it's important to inform your doctor of any complementary therapies you use.

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Review Date: 2006-09-01

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