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Melanie Cole, MS (Host): If you suffer from knee pain, you know how debilitating it can be. It can keep you from playing with your kids or your grandchildren. It can keep you from enjoying everyday activities. My guest today is Dr. Arthur Valadie. He’s a board certified orthopedic surgeon and a member of the medical staff at Manatee Memorial Hospital. Dr. Valadie, I'm so glad to have you with us today. So many millions of people suffer from knee pain. What are some of the most common causes of knee pain that you see?

Arthur Valadie M.D. (Guest): There's a variety of causes of knee pain. One of the most common ones we see is simple degenerative arthritis. That’s an age related wear and tear issue of the knee that very, very common. Afflicts millions of people. Another reason that we see knee pain is from injuries. So we’re staying active for longer and longer in life and more and more people are having traumatic knee injuries that can cause a variety of problems in the knee.

Host: Well, they certainly can. So to your point about arthritis for a minute. Is this something that we’re all destined to get? Can it be caused by shoes that we wear or high heels or any of those kinds of things? Tell us how that arthritis in our knees happens and how bad it can be for the rest of our body because it can kind of make us walk different. So our back then has trouble or our hips. It can move its way up.

Dr. Valadie:   We are definitely not all destined to get knee arthritis. In fact, you see people that are 80 years old running marathons and they don’t have a lick of knee pain. Whereas conversely you can see people that are 50 years old that have worn out their knees and need to have them replaced. So the causes of knee pain are multiple. I think shoe wear is probably one of the least significant causes. Genetics are a big deal. We know that people that have a strong family history of arthritis are more prone to get arthritis. We know that an injury at a young age definitely increases the risk of getting arthritis because it does damage to the cushioning structures of the knee. Body weight can play a role and level of activity can play a role. Now, those are all causes of degenerative arthritis. That is a little different than inflammatory or rheumatologic arthritis. That’s a different type of arthritis.

Host: Thank you for clearing that up for us. So how do you diagnose it? What the pain is and tell us about the first line of defense. What would you do if someone comes to you and it’s not an acute injury, an ACL injury or one of those. It’s really something that’s been building up over time. What do you do for them?

Dr. Valadie:   So the diagnosis is made in a variety of ways. Degenerative arthritis is much more common, and that typically causes an activity related pain that can hurt you more the more you do. So if I go and walk five miles at Disney world with the grandchildren and my knee hurts, that’s more likely to be a degenerative condition. Inflammatory arthritis, like rheumatoid arthritis, tends to effect multiple joints, can cause morning stiffness and swelling, and has a slightly different clinical picture. There are some blood tests that can pick up rheumatologic causes of arthritis, but they're not perfect. I mean you can have a rheumatologic condition and all of your blood tests will be normal. Also the x-rays will be slightly different. So usually we can look at an x-ray and tell whether it’s the more common form of wear and tear degenerative osteoarthritis or an inflammatory rheumatologic type arthritis.

Host: If somebody is an athlete, Dr. Valadie, and they come to you with some pain, and maybe it’s the first time they’ve come to you or it’s a little swollen. Are you an ice man? Do you tell them to use heat? Do you like them to brace? Before we get into some other kinds of treatments, some of the home things that we can try to keep good healthy knees. Do you like us to brace our knees? Tell us a little bit about some of those things.

Dr. Valadie:   One of the most important things we need to do is modify our activity and listen to our joints. So if I'm active and my knee is swelling and hurting, one of the best things I can do is simply rest and give it time to recover. In a relatively acute setting like this, I find ice to be better. Ice seems to have a better anti-inflammatory effect. I'm not a huge user of braces, although they can help some people. Sometimes a simple compression sleeve can give people some relief of knee pain and swelling. There are certain forms of arthritis where bracing can be helpful, but really braces play more of a role in an instability situation, an unstable knee, which is a little different than an arthritic knee.

Host: So then what? What would you do for somebody that comes, they’ve got an arthritic knee. Maybe they're not ready yet for replacement. You mentioned activity modification and exercise. What would you like them to do? What is the first thing other than those that you might try whether it’s injections or NSAIDs. Tell us about some of those modalities.

Dr. Valadie:   We utilize a slew of non-surgical treatments for knee arthritis before we ever have a discussion about knee replacement. So, again, activity modification meaning low impact activity, pool exercises, cycling, that sort of thing can make a big difference. Over the counter anti-inflammatory medications can be effective, but we have to be careful with those because they have side effects. Particularly if you’re taking a blood thinner and there’s a whole lot of people on blood thinners nowadays. Weight loss is really important. So we routinely refer people to a nutritionist that can help with their bodyweight because that plays a huge role. Strengthening exercises have been proven to diminish the pain related to knee arthritis.

There's a whole bunch of different things we can inject into the knee as well. The most common injection is steroid injection or cortisone. That basically is a potent anti-inflammatory that we put right into the knee that can calm the knee down. There's a big industry around what we call viscosupplementation. That’s an injection of a gel-like material that’s a lubricant in the knee. I will tell you the data is a bit controversial as to the effectiveness of those treatments, but there are some people to get relief of that.

One of the hottest topics in orthopedics right now is the question about regenerative medicine. Meaning can we put either proteins or cells, natural substances into the knee to provide a healing environment. The answer is maybe, but we don’t really know yet. We don’t believe that the popular “stem cell” treatments regenerate cartilage in the knee. That’s really most likely not how they work.

Host: So we’ve tried all of these things. You’ve tried cortisone injections and activity modification. When the discussion does turn to surgery, what does that discussion look like and what types of treatments can you offer?

Dr. Valadie:   So for an arthritic knee, meaning a good old fashion worn down osteoarthritic knee that’s an end stage knee that doesn’t respond to fairly extensive conservative measures, then we turn our attention to surgical options. Once there's a significant degree of arthritis then a minor operation, a small operation like an arthroscopic surgery typically doesn’t derive much benefit unless there's something loose floating around in the knee or a significant meniscus tear. Then we have a discussion about knee replacement surgery, which is basically a resurfacing of the knee or a retread job of the knee. So instead of bone on bone we now have metal on plastic, and we restore that function to the knee.

Host: Isn’t that amazing? So what about knee replacement? Both knees? One knee? Tell us what's exciting in the world of orthopedic surgery in knee replacements.

Dr. Valadie:   Knee replacements have come a long way, and interestingly everybody thinks about the implant that we put into the knee. What brand is the implant or what type is the implant? Really the biggest advances in knee replacements are how we manage blood loss and pain and a restoration of function around the time of the surgery. So really in the last five years we use a variety of medications and techniques to limit bleeding, bruising, and swelling and limit pain around the time of surgery, which can help with a really rapid recovery. Those things have made a bigger difference than any particular change in the design or style of the implant.

Host: What's recovery like? I mean how soon—If someone does have a knee replacement, how soon are they back to walking, driving, working, daily activities?

Dr. Valadie:   It’s quite variable. It’s faster than it used to be, but, again, a knee replacement in a fairly active athletic thin 55 year old than a patient who’s 80 years old and has a variety of medical conditions—heart disease, obesity, that sort of thing. So there's a wide variety or range of recovery really based on patient factors. In general I tell my patients that sometimes they can go home the same day. Sometimes they have to stay home in the hospital for a day or two, but we do healthy patients as an outpatient now letting them go home the same day. I tell them that they need to be able to walk for a short period of time, and that may vary from three days to two weeks. Most people really are reasonably mobile within a couple of weeks and really quite functional within a month. Total recovery time before you say boy this knee feels like it’s totally recovered from the surgery is variable and it can be three to six months.

Host: Such great information and what an exciting time to be an orthopedic surgeon. Do you have any final thoughts? Procedures that we haven’t mentioned? Advice on keeping healthy knees. What would you like to tell the listeners?

Dr. Valadie:   Probably stuff that they already know but sometimes it’s hard to do. So I think we need to keep our bodyweight down. We need to keep our muscles strong. We need to maintain flexibility. I'm a big believer in proper nutrition for overall health and trying to diminish the inflammatory environment that our body’s in. Then, again, if you have a problem, come see one of us who takes care of these things every day.

Host: Thank you so much Dr. Valadie. Such a pleasure to have you on and to tell us about something that so many people suffer from. They're just not sure what options are out there to help them with their knees. So thank you, again, for joining us. That wraps up this episode of Manatee Talk Radio with Manatee Memorial Hospital. For more information, you can head on over to our website at manateememorial.com for more information and to get connected with one of our providers. If you found this podcast informative as I did, please share with your friends and family. I'm sure you know people with knee problems. Share with them so they can hear from the experts as we all learn together. Physicians are independent practitioners who are not employees or agents of Manatee Memorial Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.