Regenerative Medicine for Knee Pain Associated with Degenerative Arthritis

Degenerative arthritis, or osteoarthritis, affects millions worldwide, causing pain, stiffness, and reduced mobility in the knee joints. While traditional treatments focus on managing symptoms, regenerative therapies offer a promising approach by targeting the underlying causes of degenerative arthritis and promoting tissue regeneration. In this blog article, we will explore the evaluation and treatment of degenerative arthritis of the knee, particularly emphasizing the preferential use of regenerative therapies. We will delve into the causes, symptoms, and diagnosis of knee arthritis and discuss traditional treatment options and their limitations. Furthermore, we will explore various regenerative therapies, such as prolotherapy using platelet-rich plasma (PRP), stem cells and exosomes, growth factor injections, and cartilage restoration techniques. We will examine the mechanisms of action, potential benefits, and current research surrounding these regenerative treatments. Additionally, we will address the evaluation of the effectiveness and safety of regenerative therapies and discuss the importance of an integrative approach, combining regenerative therapies with traditional treatment modalities. By delving into this topic, we hope to provide valuable insights and encourage further exploration of regenerative therapies as a potential game-changer in evaluating and treating degenerative arthritis of the knee.

Definition of degenerative arthritis of the knee.

Degenerative arthritis of the knee, also known as knee osteoarthritis, is a chronic degenerative joint condition primarily affecting the knee joint. It is the most common form of arthritis, characterized by the gradual breakdown of the cartilage that cushions and protects the joint. Cartilage is a smooth, slippery tissue that covers the ends of bones, allowing them to glide smoothly over each other during movement. Cartilage acts as a shock absorber in a healthy knee joint, facilitating pain-free motion.

In degenerative arthritis, the cartilage gradually wears away over time due to aging, genetic predisposition, joint injuries, repetitive stress, obesity, or abnormalities in articulation structure. As the cartilage deteriorates, the bones may start to rub against each other, resulting in friction, inflammation, and the formation of bony outgrowths called osteophytes or bone spurs. These changes can cause pain, swelling, stiffness, and reduced joint flexibility.

Degenerative arthritis of the knee typically develops slowly and worsens over time. It is commonly associated with aging, as the wear and tear on the joint accumulate over the years. However, it can also occur in younger individuals, especially those who have experienced knee injuries or have certain risk factors.

Degenerative arthritis is a progressive condition; without intervention, it can significantly impact a person's quality of life. However, with appropriate management and treatment with regenerative prolotherapy injections, individuals with knee arthritis can experience relief from symptoms and maintain normally active functional mobility.

Proper evaluation and diagnosis are essential for determining the presence and severity of knee arthritis. Healthcare professionals typically conduct a comprehensive physical examination, review the individual's medical history, and may order imaging tests such as X-rays or magnetic resonance imaging (MRI) to assess the condition of the joint and rule out other potential causes of knee pain.

By understanding the definition and characteristics of degenerative arthritis of the knee, individuals can seek timely evaluation and appropriate regenerative treatments, improving their symptoms and overall joint health.

Ligament laxity refers to the looseness or instability of the ligaments that support the knee joint. Ligaments are strong bands of tissue that connect bones to other bones, providing stability and preventing excessive movement. In the knee, there are several ligaments, including the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL).

In most cases, ligament laxity contributes to the development or progression of degenerative arthritis of the knee. When the ligaments become excessively loose or weakened, it disrupts the normal alignment and mechanics of the knee joint; this leads to increased stress and abnormal forces on the joint surfaces, accelerating the wear and tear of the cartilage.

Ligament laxity can be due to genetic predisposition, previous knee injuries (such as ligament tears), repetitive stress on the ligaments, or certain medical conditions that affect ligament integrity. For example, an ACL tear, a common knee injury in athletes, can result in ligament laxity and instability.

When ligament laxity coexists with degenerative arthritis, it further complicates the condition. The weakened ligaments are less effective at providing stability and support to the joint. As a result, increased joint instability leads to abnormal movement and uneven distribution of forces within the joint, accelerating the degenerative process and causing more rapid cartilage breakdown and worsening symptoms.

Managing ligament laxity in degenerative arthritis involves a comprehensive treatment approach. Prolotherapy using biological nanoparticle injections derived from different Mesenchymal Signaling Cell (MSC) sources should minimize the need for surgical interventions in the future. Our patients at IHIMC generally only require one to two treatment sessions combined with physical therapy to become virtually symptom-free despite moderate degenerative change if they remain compliant with our health optimization program.

It is important to note that ligament laxity is not always present in individuals with degenerative arthritis of the knee. If a regenerative approach is utilized before arthritis develops, not all cases of ligament laxity will lead to knee arthritis. More importantly, performing immediate regenerative treatment of damaged ligaments is crucial to prevent further cumulative damage to the joint. Preferentially, a skilled provider administers prolotherapy with an acellular biologic nanoparticle injectate (exosomes or Wharton’s Jelley derivative). Whether or not ligament laxity is present, it is a contributing factor that warrants attention and appropriate intervention to optimize outcomes in individuals with arthritis.

By addressing both ligament laxity and degenerative arthritis, healthcare professionals can provide a comprehensive approach to manage symptoms, improve joint stability, and arrest the progression of knee arthritis.

Degenerative arthritis of the knee creates physical and emotional impacts by:

• Pain and Discomfort: Degenerative arthritis of the knee is often accompanied by persistent pain and discomfort. The pain can range from mild to severe and may worsen with movement, weight-bearing activities, or prolonged periods of inactivity. The pain may significantly limit a person's ability to engage in daily activities, exercise, and enjoy hobbies or recreational pursuits.

• Reduced Mobility and Function: As degenerative arthritis progresses, joint stiffness and loss of cartilage lead to a reduced range of motion and difficulty with movement. Simple tasks such as walking, climbing stairs, or getting up from a seated position may become challenging and painful. The decreased mobility restricts an individual's independence and quality of life.

• Impact on Physical Activity: Degenerative arthritis of the knee can significantly impact an individual's ability to participate in physical activities and exercise. The fear of exacerbating pain or causing further damage to the joint may decrease overall physical activity levels, contributing to deconditioning, muscle weakness, and a sedentary lifestyle.

• Functional Limitations: The pain, stiffness, and reduced mobility caused by degenerative arthritis often lead to significant functional limitations. Individuals may need help carrying out everyday activities such as bending, kneeling, squatting, or standing for extended periods. These limitations can impact their work productivity, hinder their ability to perform household chores and restrict their participation in social activities.

• Emotional Impact: Living with chronic pain and physical limitations affect an individual's emotional well-being. The persistent discomfort and loss of mobility may lead to frustration, sadness, and even depression. The impact of degenerative arthritis on one's ability to participate in activities they once enjoyed contributes to a sense of loss and decreased quality of life.

• Sleep Disturbances: The pain and discomfort associated with knee arthritis can interfere with sleep patterns, making it difficult for individuals to find a comfortable position or get a restful night's sleep. The resulting sleep disturbances can further exacerbate fatigue and impact overall well-being.

• Impact on Relationships and Social Life: Chronic pain and functional limitations can affect relationships and social interactions. Individuals may find it challenging to participate in social events, family outings, or hobbies that require physical activity. The emotional impact of knee arthritis may also contribute to social withdrawal and feelings of isolation.

Historically a multidisciplinary team provides support, education, pain management strategies, and rehabilitation programs to help individuals cope with the challenges posed by knee arthritis and improve their overall quality of life. With the advent of the significantly improved outcomes of prolotherapy utilizing different biological nanoparticle injectates, however, the participation of supportive multidisciplinary providers may be optional in the coming years. Ask your primary provider or an experienced prolotherapist about these options.

Traditional treatment options and their limitations: Current treatment methods focus primarily on pain reduction and maintaining the suboptimal residual function of the joint. There is little, if any, focus on repairing or preventing the progression of the damage to the joint. Steroid injections, pain-related techniques, and orthotics to prevent excessive joint displacement provide some relief but allow continued deterioration. Physical therapy is as effective as arthroscopy in treating degenerative knee arthritis and is a good approach to improving the pain and function of these joints. More recently, however, it was shown to be inferior to PRP injections of the knee for degenerative arthritis insofar as it concerns pain and functional recovery.

Corticosteroid injections are associated with numerous potential adverse effects. 

Local Reactions: Some individuals may experience temporary local reactions at the injection site after the injection. These reactions can include pain, swelling, redness, and a sense of warmth or heat in the injected area. These symptoms usually subside within a few days if not infected.

Infection: Although rare, there is a risk of bacterial infection at the injection site. Signs may include increasing pain, swelling, redness, warmth, and fever.

Tendon Weakening and Rupture: corticosteroid injections in or around tendons weaken the tendon tissue, making it more prone to injury and rupture. 

Cartilage Damage: There is also an association between corticosteroid injections and cartilage damage and deterioration in weight-bearing joints such as the knee.

Systemic Effects: Corticosteroids can have many systemic effects when administered. These effects include temporary suppression of the immune system, changes in blood sugar levels (particularly in individuals with diabetes), mood changes, weight gain, elevation of blood pressure, and hormonal imbalances, particularly sexual steroid hormone imbalances leading to menstrual irregularities, mood disturbances, and electrolyte imbalances.

These effects have been noted in multiple clinical trials and meta-analyses to accelerate the deterioration of injected joints, ultimately leading to the need for stem cells or, more often, surgical interventions.

Introduction to regenerative therapies as a primary approach and preventative method to avoid the suffering and pain of degenerative arthritis of the knees.

Regenerative therapies aim to harness the body's natural healing processes to promote tissue repair and regeneration in degenerative arthritis of the knee. They offer the advantages of minimal invasiveness, reduced risk of complications, tissue regeneration, and joint repair by those biological systems and reactions inherently designed to do so, and ultimately the ability to delay or avoid surgery.

Types of regenerative therapies for knee arthritis:

• Prolotherapy:  Prolotherapy is an administrative technique that involves injecting a substance, a dextrose-based or biological solution, into the structures of the joint and its surrounding ligaments and other supporting structures to stimulate tissue repair and strengthen them and, thereby, the affected joint. However, the Hemwall-Hackett methodology pioneered in the 1940s-1950s is no longer confined to dextrose solutions but is more frequently used in conjunction with PRP, stem cells, or exosome-based solutions. These directly injected solutions have a more immediate reparative and concentrated effect on the damaged tissues that are biologically susceptible.

The evidence supporting prolotherapy's popularity is expanding, and its effectiveness is evidenced by the rapidly growing network of practitioners offering this effective treatment.  Unfortunately, the limited clinical trials base is likely due to the absence of pharmaceutical industry patentable injectates. These will undoubtedly be short in coming available given the avid research being done in this domain by industry. 

• Platelet-Rich Plasma (PRP) Therapy:  PRP therapy uses concentrated platelets from the patient's blood to stimulate tissue healing and reduce inflammation. Research supports the potential effectiveness of PRP therapy in reducing pain and improving knee function. Considerations include variable treatment outcomes (the use of 3 or more sessions of prolotherapy with PRP as the injectate is not unusual to obtain near pain-free function), potential transient discomfort, and limited insurance coverage.

• Stem Cell Therapy and MSC Derivative Acellular Nanoparticle Therapies: Stem cells can be derived from various sources (e.g., bone marrow, adipose tissue,  placenta,  umbilical cord, and amniotic membranes) and injected into the knee joint to promote tissue regeneration and reduce inflammation. These components have been shown to enhance cartilage repair and modulation of the joint environment. Ongoing research, clinical trials, and effective use in the community clinic environment have demonstrated the safety and efficacy of stem cells and acellular MSC derivative component (exosomes) therapy for knee arthritis.

• Growth Factor Injections: Growth factors, such as platelet-derived or insulin-like growth factors, can be injected into the knee joint to promote tissue healing and regeneration. These injections may provide pain reduction, improved function, and potential cartilage repair  Considerations include variable treatment responses and the need for further research to optimize protocols and determine long-term outcomes.

• Cartilage Restoration Techniques: Autologous chondrocyte implantation (ACI) and matrix-induced autologous chondrocyte implantation (MACI) are surgical procedures that involve implanting cultured cartilage cells into damaged areas of the knee joint. These techniques aim to restore cartilage and improve joint function, particularly in younger patients with localized defects.

Potential Risks and Side Effects of Regenerative Therapies for Degenerative Arthritis of the Knee: Regenerative therapies for degenerative arthritis of the knee show promise, but like any medical intervention, they come with potential risks and side effects. 

• Infection: Whenever an injection or surgical procedure is performed, there is a risk of infection. Although the risk is generally low, it is essential to ensure that all equipment and techniques used in regenerative therapies follow strict sterile protocols to minimize this risk.
• Pain or Discomfort: Some individuals may experience increased pain or discomfort at the injection site following regenerative therapies. The discomfort experienced by the use of different injectates may vary widely , PRP seems to cause greater injection  discomfort than does wharton’s Jelly or exosome formulations. The pain is generally shortlived and can be managed with over-the-counter pain relievers. 

• Allergic Reactions:  In exceptional cases, individuals may experience allergic reactions to a substance used in regenerative therapies. . This eventuality has not beed evidenced in my hands with over 1000 procedures including 1-300 injections/procedure to date. 

• Lack of Efficacy: Regenerative therapies are still a relatively new area of research, and their effectiveness varies from person to person. While most individuals experience positive outcomes, some may not see significant improvement in their symptoms. Data on simple dextrose prolotherapy suggest a minimum of 50% reduction of pain in 95% or greater of the cases treated for musculo skeletal disorders.

• Long-Term Safety: As regenerative therapies are relatively new, the long-term safety and potential side effects are still being studied. It is essential to proceed with caution and consult with a qualified healthcare professional who is experienced in these therapies.

• Lack of Standardization: The field of regenerative therapies is continually evolving, and there may not be uniform standards for the procedures or substances used. Variability in techniques and products can impact treatment outcomes.
• Ethical Considerations: Some regenerative therapies involve the use of stem cells, which raises ethical considerations related to their sourcing and use. It is crucial to ensure that all procedures adhere to ethical guidelines and regulatory standards.

Healthcare professionals can help assess the appropriateness of regenerative therapies based on the individual's medical history, current health status, and the severity of knee arthritis. By making informed decisions and being aware of potential risks, individuals can approach regenerative therapies with a balanced perspective and maximize the potential benefits while minimizing potential adverse effects.

In summary, regenerative therapies for knee arthritis encompass a range of approaches, including PRP therapy, stem cell therapy, prolotherapy, growth factor injections, and cartilage restoration techniques. While these therapies show promise in promoting tissue healing and reducing symptoms, further research is needed to optimize protocols, establish long-term efficacy, and determine patient selection criteria.

Understanding Degenerative Arthritis of the Knee:

• Causes and Risk Factors: Degenerative arthritis of the knee, or osteoarthritis, is influenced by age, obesity, joint injuries, genetic factors, and mechanical stress.
• Pathophysiology and Progression: Knee arthritis involves the gradual breakdown of cartilage, remodeling of bone, and inflammation of the synovium, leading to pain, stiffness, and limited joint function.
• Common Symptoms and Impact: Symptoms of knee arthritis include joint pain, stiffness, limited range of motion, swelling, and functional limitations that can affect daily activities.
• Diagnosis and Evaluation: Diagnosis involves a physical examination, imaging studies (X-rays, MRI), joint fluid analysis, and occasionally, arthroscopy to assess cartilage damage and joint integrity.

Traditional Treatment Options for Degenerative Arthritis of the Knee 

Surgical interventions: 

Arthroscopy for joint cleaning and repairs:  This intervention is the single most frequently performed surgery in the United States. It has likewise been shown in multiple randomized clinical trials and meta-analyses to accelerate the progression to open surgery and joint replacement surgeries of the knees. More recently, the utility of these surgeries has been openly reviewed compared to simple physical therapy and found lacking insofar as concerns pain relief and return to normal activities of daily living at six months and twelve months following treatment. 

Partial or total knee replacement: This approach has a track record of just shy of 50% for pain relief and functional recovery. The operative and anesthesia risks, as well as threats of debilitating post-operative infection, paired with the poor track record for pain resolution and return to function, these procedures are the interventions of last resort in this author's opinion.

In Conclusion…

Degenerative arthritis of the knee is characterized by the progressive breakdown of cartilage in the knee joint, leading to pain, stiffness, and reduced mobility. It significantly impacts the quality of life for affected individuals.

Regenerative therapies have emerged as a valuable approach for treating degenerative arthritis of the knee in my hands. These therapies stimulate the body's natural healing mechanisms and promote tissue regeneration. Examples include platelet-rich plasma (PRP) injections, stem cell and stem cell-derived acellular nanoparticle therapies, and platelet and MSC-derived growth factor treatments.

Further research and exploration in regenerative therapies for degenerative arthritis are encouraged. Ongoing studies seek to improve the effectiveness and safety of these treatments, identify optimal patient selection criteria, and refine the techniques involved.

For more information and to find out if you are a qualified candidate for one of our regenerative medicine modalities for your knee pain visit www.YourInfiniteHealth.com and schedule a free discovery call with one of our wellness coordinators.