Edema of the knee arthrosis

Attention: this article is not a self-help manual, but is informational and fact-finding.
Only the doctor can prescribe the treatment, after due examination of the problem joint.

Fulfilling the promise I once made, I representto your attention this article on gonarthrosis. In principle, the information outlined in the article is relevant for arthrosis of any joints, because they all have similar pathomorphology, but since gonarthrosis is the most relevant for athletes, let's talk about them. This article does not claim a scientific monograph, but it contains the information necessary to recognize the disease at an early stage, to distinguish gonarthrosis from other joint pathologies and take all necessary measures.


A little anatomy and physiology of the joints:

In general, the synovial environment of the joint consists of three main components - the synovial membrane, the synovial fluid and the cartilaginous tissue proper.
Cartilage tissue of an adult does not containblood vessels, and has two main sources of nutrition - the synovial fluid that is washing the cartilage of the articular surfaces of bones, and the blood that enters through the capillaries, adjacent to the cartilage on the side of the subchondral bone.

Consequently, in the normal metabolic processes in the cartilage of the joint, peripheral circulation and the water-salt balance of the organism are important.
Hyaline cartilage consists of chondrocytes and a matrix that contains a strong framework formed by collagen fibers and a basic substance consisting of proteoglycans and glycoproteins.
The combination of the properties of the cartilaginous matrix components-the elasticity of glycoproteins and the strength of collagen fibers provides both the strength and lability of the joint.
And proteoglycans keep up to 70% of water in cartilage.

In a normally functioning joint, the jointsthe surfaces almost do not touch each other, and the friction occurs within the lubricant, the amount and concentration of which can vary depending on the load applied to the joint. This is due to the ability of glycosaminoglycans to bind and release water, adapting the joint to an external load.
Such an elastodynamic system is very reliable, as long as at least one component that forms it is violated.

Articular cartilage is smeared as a result ofinteraction of the two main mechanisms: the formation of a protective film on the surface of the cartilage from the components of the synovial fluid and the entry into the joint cavity of the fluid that is squeezed out from the matrix. This liquid takes over most of the compression pressure, thus preventing the protective film.

Proceeding from the foregoing, we see that for the normal operation of the joint, it is necessary:
a) a sufficient content of glycosamines and proteoglycans
b) a sufficient amount of water
c) absence of decompensation in the peripheral circulation.


Etiology and pathogenesis of gonarthrosis:

Etiology and pathogenesis of primary arthrosisare not fully understood. Among the etiological factors contributing to the development of local manifestations of the disease, the first place is occupied by a static load exceeding the joint capabilities and mechanical microtraction. With age, changes occur in the vessels of the synovium. An important role is also given to some endocrine disorders, especially an increase in the activity of the growth hormone of the pituitary gland, a decrease in the function of the thyroid and sex glands.

In addition, the importance of infectious,allergic and toxic factors. A definite role of the pathology of crural veins in the development of arthrosis of knee joints has been noted. There are also data indicating the role of heredity in the etiology of arthrosis. In the light of modern concepts, the pathological process in the joints develops depending on predisposing factors. Prolonged microtraumatism, like exercise, first of all causes changes in the ligamentous apparatus, articular capsule and other periarticular soft tissues, and then in the synovial membrane, which leads to the formation of an inferior synovial fluid. The change in the physico-chemical composition of the synovial fluid is the main cause of the disturbance of the normal state of the cartilaginous tissue. When treating this particular disease, one has to face a huge number of diagnostic and therapeutic errors.

Osteoarthritis of the knee joint (gonarthrosis), asthe rule is somewhat lighter than arthrosis of other joints, and less often leads to disability. More often than others, women and those with varicose veins of the lower extremities are affected. In this case, arthrosis usually affects both knees, but it happens that for a long time the pain is felt only in one joint. The disease begins gradually, with minor pain when walking. The patients are most difficult to descend and climb the stairs. Sometimes pain occurs if a person has to stand for a long time.

When the knee is swollen (synovitis), it may be impairedoutflow of blood and there is soreness of calves. Especially strongly "twists" caviar at night. Gradually the joint is deformed, and the pain intensifies. Reduces the ability to normally bend the leg. When trying to bend the knee "to the stop" there is a crunch and a sharp pain in the joint. In addition, in the third stage of the disease, the opportunity disappears completely, that is, to straighten the leg. The sick person always walks on slightly bent legs.

The overall picture of the disease and the appearance of the joints inthe pronounced clinical stage of gonarthrosis is so characteristic that it is not difficult to correctly diagnose it. Treatment should be started earlier, but in the first stages of the disease and doctors often manage not to notice gonarthrosis, and patients rarely seek help on time. In addition, gonarthrosis is often combined with other lesions of the knee joint, and one disease is superimposed on the other, which complicates the diagnosis.

Thus, gonarthrosis often occurs in parallel withmeniscopathy of the knee joints, which is expressed by tearing or infringement of menisci. In many cases, meniscopathy even becomes one of the causes of arthrosis. And how this happens, let's take a closer look, especially since meniscopathies are quite common and often infect people of young age. Especially suffer from this disease athletes. In young people, meniscopathy is manifested, as a rule, acutely. At the time, as for arthrosis is characterized by the gradual development of clinical symptoms.

During unsuccessful movement occursdamage to the meniscus, there is a sharp pain and the knee swells. If at once, or at least within the next three days, repositioning is done - the manicus is being guided by manual methods, then there is a chance that the damage will pass without consequences. However, in most cases, meniscopathy is tried in our outpatient clinics not with manual manipulations, but with medicines and physiotherapy. As a result, pain and swelling can be partially removed, but the infringement of the meniscus becomes chronic. The articular surfaces of the knee are not ideally adjusted to each other, the redistribution of the load in the joint changes, which eventually leads to arthrosis. Sometimes meniscopathy is treated radically - remove the injured meniscus in an operative way.

Undoubtedly, there are situations when such aThe operation is necessary (for example, when the infringement of the same meniscus is repeated 2 to 3 times), but I believe that in most cases, the primary damage to the meniscus should be tried by therapeutic methods. Although the operation leads to a rapid restoration of the functions of the damaged joint, but in the future, the absence of a meniscus in the knee promotes the development of the same arthrosis. We must understand that nature does not create too much, and since it has awarded us with meniscuses, it means that they are needed. Menisci stabilize the joint when it moves, and their absence leads to increased stress on certain articular structures that cause the gradual destruction of cartilage. I had to see how after the operation to remove meniscus (meniskectomy), even 30 to 35-year-old young people developed arthrosis, which should not be at this age.

During the deforming arthrosis, there are 3 stages:

Stage I is characterized by fatiguelimb, moderate restriction of movements in the joint, a small crunch is possible. In rest and a small nagruzke pains are absent. Usually, pain occurs at the beginning of walking - "starting pain" or after a long load. X-ray reveals the narrowing of the joint gap due to chondrolisis and a slight subchondral sclerosis.

II stage is characterized by an increase in the limitationmovements that are accompanied by crepitation. Sharply expressed pain syndrome, diminishing only after a long rest. There is deformation of the joint, hypotrophy of the muscles, contracture of the joint, lameness. X-ray reveals a narrowing of the joint gap 2-3 times in comparison with the norm, subchondral sclerosis is expressed, osteophytes in places of the least load.

Stage III is characterized by almost complete lossmobility in the joint, only passive swinging movements are preserved, flexural contracture is expressed. The pains persist and at rest, do not pass after rest. Possible instability of the joint. Radiographically - articular fissure is almost completely absent. The articular surface is deformed, the marginal expansions are expressed. Multiple cysts are revealed in the subchondral areas of joint surfaces.

The main methods of treatment of gonarthrosis.

A. Drugs in tablets, candles, injections 1. Non-steroidal anti-inflammatory drugs (NSAIDs)

With the prescription of drugs of this group, most doctors begin treatment of any joint diseases. From these drugs, as the most effective, I recommend:

MOVALIS. KSEFOKAM, VOLTAIN, AERTAL

With gonarthrosis, anti-inflammatory drugsare used in those cases when it is necessary to eliminate the edema and swelling of the joint, that is, to remove the inflammation. The anti-inflammatory drugs themselves can not cure arthrosis, but they can significantly alleviate the patient's condition and reduce joint pain during the period of exacerbation of the disease. So, by eliminating the aggravation of arthrosis with these medications, we can then move on to other medical procedures - say, massage, physiotherapy, LPC - which, because of the pain and swelling, would not be possible.

NSAIDs are usually given in the form of injections. Candles or oral, in parallel with the local application of ointments or gels of NSAIDs to the affected joints. Like this:

VOLTAIN-GEL, NIMESULID, DIKLOGEN, INDOMITOZIN, DOLGIT

2. Chondroprotectors (glucosamine and chondroitin sulfate) -

preparations for the restoration of cartilaginous tissue. Glucosamine and chondroitin sulfate are referred to a group of chondroprotectors - substances that feed cartilage tissue and restore the structure of damaged cartilage of joints. This is the most useful group of drugs for the treatment of arthrosis.
Unlike NSAIDs, chondroprotectors are not so mucheliminate the symptoms of osteoarthritis, how much affect the "basis" of the disease, although "work" glucosamine and chondroitin sulfate in different ways and each fulfills its own particular task.

The combined use of glucosamine andchondroitin sulfate promotes the restoration of the cartilaginous surfaces of the joint, the improvement of articular fluid production and the normalization of its "lubricating" properties. Such a complex effect of the chondroprotectors on the joint makes them indispensable in the treatment of the initial stage of arthrosis. However, there is no need to exaggerate the possibilities of these drugs.

Chondroprotectors are absolutely useless in the thirdstage of arthrosis, when the cartilage is almost completely destroyed. Influence on bone deformities or to grow a new cartilaginous tissue with the help of glucosamine and chondroitin sulfate is impossible. And with the first - the second stages of arthrosis, chondroprotectors act very slowly and improve the patient's condition far from immediately. To get a real result, you need to undergo at least 2 to 3 courses of treatment with these drugs, which usually takes half a year or a year, although advertising with glucosamine and chondroitin sulfate usually promises recovery in a shorter period.

I want to note with regret that in these promisesthere is some guile. With all the usefulness of chondroprotectors of miraculous medicinal healing, arthrosis can not be expected. Recovery usually requires much more effort than taking two to three dozen tablets. So, how to use glucosamine and chondroitin sulfate to achieve the maximum therapeutic effect? First, they are best used together.

Although glucosamine and chondroitin sulfate give a goodthe result and individually, the benefits of their integrated application will undoubtedly be higher. They complement and enhance each other's possibilities. Secondly, chondroprotectors should be used on a regular basis, at least twice a year. It is practically meaningless to take glucosamine and chondroitin sulfate once or occasionally. In addition, in order to obtain the maximum effect from the use of chondroprotectors, it is necessary to ensure the daily intake in the body of adequate, that is, sufficient doses of drugs throughout the course of treatment.

A sufficient daily dose of glucosamineis 1500 mg (milligram), and chondroitin sulfate - 1000 mg. The duration of treatment with glucosamine and chondroitin sulfate may be different, but most often I offer my patients 2 options: either a forty-day cycle every six months, or once every 3 months, but with courses of 20 days each. That is, in one way or another, the intake of glucosamine and chondroitin sulfate is recommended to be performed approximately 80 days a year for at least 3 to 5 years. Attention! When choosing chondroprotective drugs, also pay attention not to advertising, but to the composition and dose of the active substance in the medicine. Keep in mind that the cost of the same drugs, produced under different names, can vary 5 to 10 times.
My personal hit parade of chondroprotectors is as follows:

1. Aflutop
2. Chondrolon (Rumalon)
3. Teraflex
4. Joint Flex
5. Don
6. Structrum.

3. Vasodilators are pentoxifylline (he is trental), xanthinal nicotinate (aka theonikol), nikoshpan. With gonarthrosis, there is almost always a stagnation of blood in the joint region, which often causes night "bursting" pain. In these cases, the reception of vasodilator drugs has a pronounced positive effect, removing the spasm of small vessels of the legs and restoring blood circulation in the joint. It is especially useful to use vasodilator drugs in combination with chondroprotectors. In this case, chondroprotective nutrients penetrate into the joint more easily and in a larger amount, and also circulate more actively in it. B. Intraarticular Injections

1. Intra-articular injections of corticosteroid hormones - Kenalog (triamcinolone), diprospan (betamethasone), flosteron (betamethasone), hydrocortisone. This is something that I do not recommend to do, although this method of treatment is most common among surgeons and orthopedists in polyclinics because of its almost instantaneous action. After 1-2 hours after intra-articular injection, pain usually passes completely, and the person feels "healthy". However, in fact, this is called "drowning the symptoms." Despite the pain and inflammation removed, degenerative disorders in articular cartilage have not disappeared anywhere. And the disappearance of pain gives a person the ability to load in essence, a sick joint, as healthy.

In addition, the corticosteroids themselvespronounced destructive effect on the cartilaginous tissue of the joint, cause narrowing of the vessels, blood supplying the joint. The use of these injections in gonarthrosis makes sense only to suppress inflammation in the joint, to remove severe pain in the last stages of gonarthrosis. In this case, intra-articular injection of hormonal drugs will bring rapid relief. However, it must be remembered that it is undesirable to repeat such injections more often than once every 2 weeks. You also need to know that the first injection will bring more relief than the subsequent ones, respectively. If the first has not given a result, it is unlikely that it will be given by the second or third. In this case, more than three times to inject hormones into one joint is generally undesirable - the probability of side effects increases.

2. Intraarticular injections of chondroprotectors (arteparone, target T) and enzymes (countercracker, gordoks). Unlike hormones do not apply if there is a swelling of the joint, since almost no suppresses inflammation. But they are good for the initial stages of gonarthrosis, which proceeds without an edema of the joint (synovitis). In this case, intra-articular injections of chondroprotectors contribute to the partial restoration of the cartilaginous tissue. To a minus of such intraarticular introductions it is possible to carry necessity to spend treatment by a course in 5-10 injections; while each intra-articular injection still to some extent injures the tissues of the joint.

3. Intra-articular hyaluronic acid injections (Synvisc, Ostenil, Fermatron). Intra-articular introduction of hyaluronic acid preparations into the joint is a new effective but expensive method of treating gonarthrosis. Hyaluronic acid is a "lubricant" for the joint, its composition is very close to the natural lubrication of the knee. Introduced in a painful joint, hyaluronic acid reduces the friction of damaged joint surfaces and improves knee mobility, protects it from physical effects. The effectiveness of hyaluronic acid preparations is very high for gonarthrosis I (initial) stage, less for arthrosis of stage II. In arthrosis of the knee joint of the third stage, preparations of hyaluronic acid can alleviate the suffering of the patient, but most likely for a short time. In ordinary cases, hyaluronic acid treatment is carried out with a course of 3 to 4 injections in each diseased joint. This course is repeated on average once a year. Minus of hyaluronic acid preparations is a high price. Currently, the price of 1 ampoule of medicine varies in Russia within the range of 80 - 90 US dollars. The course of treatment of one joint requires 3 to 4 ampoules of medication, which means that such treatment will cost the patient at least 320-360 dollars.

P.S. Chondroprotectors Aflutop and Arthra.

In principle, drugs similar in effect andcomposition. But I prefer ampoule forms tabletted. due to better digestibility of the drug, and less risk of running into a fake. Tableted chondroprotekroras are often falsified, and ampoules are not. for it is expensive and troublesome.
But if something has gone on, the perfect option is our HONDROLON.
Excellent results are provided by JOINT FLEX by Art Life.
I'm talking about the drugs with which I have been working for many years and have an opportunity to objectively judge their clinical effectiveness,
tracking long-term dynamics in their patients.

As for the Vitafon and other devices of "home physiotherapy," I can only say that the physiotherapy devices that are used in clinical practice cost a lot of money.
Although a certain analgesic and trophostimulating effect, the same Vitafon or Denas possess.
But it is not possible to exert any influence on the degenerative processes in the joint.
Here, the first place in the effectiveness of exposure is qualified laser therapy.

B. Local medicines: ointments, compresses

Due to the fact that the knee joint does not liedeep under the skin, in case of complex treatment it is useful to use local remedies - they improve blood circulation in the joint, sometimes help to eliminate pain. One of the best local remedies is dimexid-a liquid that has an anti-inflammatory effect, helps to remove swelling of the joint. However, dimexide must be used carefully, because It can cause severe allergies and even sensitive people have a burn. Before using, you need to test for sensitivity: apply a few drops of medication on the skin and watch the reaction. If strong redness and burning sensation develops, dimexide should be immediately discarded and no longer used.

With arthrosis of the knee joints, it can bringpatient significant relief. First of all I would like to advise laser therapy, massage and electrophoresis of medicines. These procedures improve the condition of the tissues and blood circulation in the joint, reduce inflammation and relieve painful muscle spasms. But they also have contraindications. Such procedures should be administered with caution to people suffering from hypertension and heart disease, with tumors (even benign), infections and inflammatory joint diseases. In addition, physiotherapy is not prescribed during exacerbation of arthrosis of the knee joint, flowing with edema and reddening of the knee. This exacerbation must be previously eliminated, and only then begin physiotherapy treatment.

D. Extension of the joint (traction).

As with arthrosis of the hip joint, tractionThe knee is performed by the methods of manual therapy or by means of a traction apparatus. Extension is made to dilute the bones, increasing the distance between them and thus reducing the load on the joint. However, in the treatment of the knee joint, it is necessary to act immediately on 4 contiguous bones, since the knee joint consists of three joints, and it is necessary to carefully influence the most damaged, which requires jewelry accuracy and load calculation. Even with absolutely competent actions of a specialist, it is not always possible to achieve complete success, especially if the deformation of bones has gone too far. But in general, approximately 80% of cases of joint extension produce good results, especially if combined with drug therapy and physiotherapy.

Blocking of the knee joint. "Articulated Mouse"

In orthopedic and manual practice, veryoften occurs so-called. syndrome of the "articular mouse", which by mechanism is similar to the meniscopathy described above, but differs from it in that it is not the meniscus that is impaired, but that which is detached from the meniscus. as a result of its separation a piece - meniscoid The mechanism of joint blocking with this syndrome is as follows:
• Infringement of the meniscoid due to its retraction between the articular surfaces.
• Changing proprioceptions causes reactive muscle joint fixation
• Intensive nociception (painful pulsation) causes fixation of the joint in the position of the least soreness (muscular analgesic contracture)
• Infringement of the meniscoid causes microcirculation disturbance, causing swelling and swelling of the stroma, which leads to deformation of the cartilage.
• Prolonged existence of the block leads to disruption of biomechanics, decompensation of trophics and development of destructive processes in the cartilage.
The above symptomatology developspromptly - for 1-3 days, and requires primarily an intervention manual therapist, which through traction manipulation will release the contracted between the articular surfaces of the meniscoid.
However, the released meniscoid remains within the joint cavity, and the likelihood of recurrence of its infringement is extremely high.
In this case arthroscopy of the joint is shown for the detection and removal of the "articular mouse".

Subcooling, dehydration, and functionaloverloads (static and dynamic) are the main factors contributing to the development of degenerative processes in the cartilage. Actually, all prevention is reduced to minimizing the impact of these factors on the joints. And it is worth remembering that our musculoskeletal system has only one way of protecting against our not always adequate brains in relation to it - this is pain. Pain is a signaling factor, and a factor that realizes sanogenetic, reflex and adaptive defense mechanisms that do not allow aggravating the problem that has arisen in any ODA system.
Therefore, ignoring this factor, as a rule, is fraught.

VE Raskin
A vertebrologist, a manual therapist,
Director of Rehabilitation Center REAMED Novokuznetsk.

Used Books: Michael Doherty "Clinical Diagnosis of Diseasesjoints ", IA Reutsky" Physical diagnostics of diseases of joints, muscles, fascia, tendons ", Karel Levit" Manual therapy ", VP Evdokimenko" Gonarthrosis "," Methodological manual on diagnosis and treatment of deforming arthrosis of joints "(Team authors, Kazan State Medical Academy.) GA Ivanichev "Manual therapy", AM Veyn "Pain and anesthesia".
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Last edited by Sibman; 9/25/2009 at 06:18.

Hush is less - less Russian.

Thank you for the article!
Vadim, it would be interesting to compare the chondroprotectors Aflutop and Arthra. [/ B]

In principle, drugs similar in effect andcomposition. But I prefer ampoule forms tabletted. due to better digestibility of the drug, and less risk of running into a fake. Tableted chondroprotekroras are often falsified, and ampoules are not. for it is expensive and troublesome.
But if that's gone, then the perfect option is our HONDROLON.
Excellent results are provided by JOINT FLEX by Art Life.
I'm talking about the drugs with which I have been working for many years and have an opportunity to objectively judge their clinical effectiveness,
tracking long-term dynamics in their patients.

As for the Vitafon and other devices of "home physiotherapy," I can only say that the physiotherapy devices that are used in clinical practice cost a lot of money.
Although a certain analgesic and trophostimulating effect, the same Vitafon or Denas possess.
But it is not possible to exert any influence on the degenerative processes in the joint.
Here, the first place in the effectiveness of exposure is qualified laser therapy.

Added later (05/06/2008 05:38):
<div class = 'quotetop'> Quotation ([email protected] 17:14) <> </ div></ p>

I read the article of uncle Vadim - everything was ill. You can not scare so much! [/ B]