Treating knee osteoarthritis in the aging athlete

Ross Hauser, MD

In this article Ross Hauser, MD discusses the various treatment options for the aging athlete suffering from osteoarthritis.

If you have a question about your osteoarthritis options, get help and information from our Caring Medical staff

Aging, or commonly referred to as “Masters” athletes are able to continue participating in sports because they have good mobility and it is pain-free mobility.

Once mobility declines, once pain prevents participation, the aging athlete is faced with the reality of giving up their sport or getting medical treatment.

If you are a maturing athlete and you suffer from osteoarthritis, you may think that surgery is the answer to getting you back to your sport quickly. Research is now routinely debunking this line of thinking in favor of rejuvenation of damaged joints.

I want to play pickleball again

For most people that contact our office, a recommendation for knee replacement has already been given. For some patients there may be a prolonged wait to get the surgery. Then there is a concern about extended recovery. Many, many people do very well with knee replacement. Some people are hesitant because they want to be active and would like to try alternatives.

Here are some emails we get into our center, they probably tell a very familiar story to your own.

“I have bone on bone knee pain and I am thinking of getting knee replacement. I am wondering if exercises can strengthen my knee to the point of not needing surgery. What is the research on platelet rich plasma?” Please see our article Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not work.

What do we say to someone like this?

If they have limited range of motion or their knee has significant bone spurs that prevents the knee from achieving a full range of motion. Knee replacement may be needed.

What about exercise?

We do see many patients who have reached a point where physical therapy is no longer helping. They have been dealing with their knee pain for years. They have also been trying to avoid a knee replacement surgery. Initially, chiropractic helped them, physical therapy helped them, and exercise and yoga helped them. But now these once effective means of alleviating their knee pain are no longer helping and in some people are now making their situation worse. Their pain is also spreading.

I want to golf again

A lot of people play golf with knee pain. Many golfers play through pain with the help of various remedies and self-help treatments. Eventually, their knee will hurt them so much that they will seek out medical attention. For many people, this medical attention will be very successful. For others, the medical attention they sought sent them on a journey of surgical recommendations and waiting for their knee to get so bad that they will be considered candidates for knee replacement. Once confirmed for knee replacement, some of these people become that group of patients that seek advice on how to avoid the knee replacement and some will seek advice on how to play after knee replacement in a knee that is causing issues. Please see our article I would like to play golf again – Knee pain, knee replacement and golf.

The greatest threat to the health of the aging athlete is not the aging process itself but rather inactivity

In a recent paper, doctors at Stanford warned that “The greatest threat to the health of the aging athlete is not the aging process itself but rather inactivity. Motion is critical to articular cartilage health, repair, and homeostasis (a healing joint environment).”(1)

What the Stanford doctors are saying is that weight-bearing stress on the joint and mobilization is a self-reparative mechanism.

Here is more from the Stanford paper: “Articular cartilage has a unique functional architecture capable of providing a lifetime of pain-free joint motion. This tissue, however, undergoes substantial age-related physiologic, mechanical, biochemical, and functional changes that reduce its ability to overcome the effects of mechanical stress and injury. . . is important to the development of new strategies to rejuvenate aging joints.”

In other words, these researchers are calling for new strategies because:

You can’t repair damaged cartilage with surgery, the most common of which is arthroscopy which numerous medical studies found to be no more effective than placebo.
Nor can you repair damaged cartilage with standard osteoarthritis treatments that involve symptom management such as NSAIDS, and cortisone shots.

Our strategy at Caring Medical is to treat joint instability and cartilage wear and tear with a comprehensive Prolotherapy program including Platelet Rich Plasma Therapy and Stem Cell injections. These treatments are explained below and the accompanying videos.

When overload is the problem

Many people we see, especially those who have physically demanding lines of work or older athletes, there desire to work through or play through their knee problems are now adding to making their problems much worse.

An April 2017 paper in The Journal of rheumatology (2) makes this plain to understand:

“Mechanical loading changes proteoglycan content.” (Explanatory note: Proteoglycans are shock absorbers. In most simplest terms they are proteins that have the capacity to “absorb” water and make themselves into a pad or cushion.)

“Moderate mechanical loading causes hypertrophy and reduced mechanical loading causes atrophy.” (When you are active, like running, taking a golf swing, carrying a load at the worksite, the mechanical load on your knees is buffered (hypertrophy) by the proteoglycan’s ability to absorb water and become a pad. This is what is supposed to happen in moderate overloading)

“Overloading produces collagen network damage and proteoglycan loss, leading to irreversible cartilage destruction because of lack of regenerative capacity.” (At some point you have yourself reached the point of cartilage damage and your knees are now moving into a situation where if the load on them continue, they will develop irreversible damage).

What are we seeing in this image? How irreversible knee damage starts?

The progression of knee osteoarthritis. A simple ligament injury can eventually lead to a bone on bone knee situation.

Osteoarthritis does indeed start with ligament damage.

Osteoarthritis does not have a simple explanation although a clear path to its eventuality can be made.

Joint instability through ligament injury comes before bone and cartilage degeneration in osteoarthritis. This is discussed in more detail in my article The progression from Joint Instability to Osteoarthritis and Degenerative joint disease.

In a landmark article published in the medical journal Gerontology researchers confirmed this observation that osteoarthritis does indeed start with ligament damage.

The researchers conclusion makes it clear:

The reversal of the current concepts of how osteoarthritis begins needs to be shifted from cartilage and bone damage first to that of damaged ligaments and that treatment strategies could be effectively redirected (to the role of ligament laxity and injury).”(3)

Taking into account the progression of osteoarthritis with a ligament damage origin, it becomes clear that the ligament integrity or lack of integrity is what needs to be treated to prevent further joint destruction.

Prolotherapy, PRP, and stem cells restore joint integrity

Prolotherapy injected into the painful sites where ligaments and tendons connect to bone, as well as at trigger points and adjacent joint spaces, produces an inflammatory response involving fibroblastic and capillary proliferation, along with growth factor stimulation, that induces healing and strengthening of the damaged or diseased structure. This repairs the damaged ligaments and soft tissue, and allows the older athlete to continue with their desired activity.

The research surround Prolotherapy’s success in treating ligament damage can be found here on our introduction Prolotherapy and Prolotherapy research.

Patients treated with Bone Marrow Prolotherapy reported significantly decreased pain and significantly increased function in all areas measured, including gains in activities of daily living, exercise ability, and range of motion

Stem cells represents a non-surgical option for the repair of osteoarthritic cartilage changes and relieve symptoms of stiffness, pain, disability, and inability to run or even walk.

Doctors at the Steadman Philippon Research Institute in Colorado reported in their research published in the journal Sports Medicine, on the rising popularity of PRP and stem cell injections for osteoarthritis in the aging athlete.

Growth factors, platelet-rich plasma (PRP), concentrated bone marrow aspirate, and other stem cell therapies intended to treat inflammatory or degenerative conditions have spawned much interest in recent years. Previous studies have shown that the application of concentrated growth factors and autologous stem cells may stimulate healing in tissues that have a limited ability for self-regeneration. While the use of stem cell therapy to treat knee osteoarthritis is still in early development, preliminary results appear promising. Mesenchymal stem cells from bone marrow and adipose tissues are capable of differentiation into chondrocytes and can be injected into the knee joint along with platelets and growth factors after concentrating.(4)

From our own research in the Open Arthritis Journal,

“Patients treated with Bone Marrow Prolotherapy (BMP) reported significantly decreased pain and significantly increased function in all areas measured, including gains in activities of daily living, exercise ability, and range of motion, as well as losses in stiffness and crepitus. Furthermore, we propose that BMP treatment has the potential to slow and possibly reverse progression of osteoarthritis in joints by promoting the regeneration of articular cartilage.”(5)

Please see my article Stem Cells and Prolotherapy for Knee Osteoarthritis and Cartilage Regeneration for a more detailed discuss of stem cells.

Prolotherapy, PRP, and stem cells for back pain in master athletes

In our opinion, Prolotherapy is the treatment of choice for treating low back pain in older athletes, due to spinal instability caused by ligament weakness in the lower back and not due to degenerative disc disease. Please see our article on degenerative disc disease.

If you have a question about your osteoarthritis options, get help and information from our Caring Medical staff

1 Luria A, Chu CR. Articular Cartilage Changes in Maturing Athletes: New Targets for Joint Rejuvenation. Sports Health. 2014;6(1):18-30. doi:10.1177/1941738113514369. [Google Scholar]
2 Jørgensen AE, Kjær M, Heinemeier KM. The effect of aging and mechanical loading on the metabolism of articular cartilage. The Journal of rheumatology. 2017 Apr 1;44(4):410-7. [Google Scholar]
3 Bailey AJ, Mansell JP. Do subchondral bone changes exacerbate or precede articular cartilage destruction in osteoarthritis of the elderly? Gerontology 1997; 43:296-304.[Google Scholar]
4 Chahla J, Dean CS, Moatshe G, Pascual-Garrido C, Serra Cruz R, LaPrade RF. Concentrated bone marrow aspirate for the treatment of chondral injuries and osteoarthritis of the knee: a systematic review of outcomes. Orthopaedic journal of sports medicine. 2016 Jan 13;4(1):2325967115625481. [Google Scholar]
5 Hauser R, Woldin B. Treating Osteoarthritic Joints Using Dextrose Prolotherapy and Direct Bone Marrow Aspirate Injection Therapy. Open Arthritis J. 2014; 7:1-9. [Google Scholar]

This article was updated August 24, 2021