Chronic knee swelling research: Patients do not know how bad their inflammation is or how destructive it is to their knees
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Knee Synovitis – Knee Swelling and Synovial inflammation
In this article, we will examine synovial inflammation of the knee as a result of knee instability and osteoarthritis and discuss treatment options.
- You have a problem with knee swelling.
- The problem is very obvious to you. You are looking at your knees and they are puffy and filled with water.
- You can’t bend your knee to get in an out of a car or a chair. Sometimes you have to figure out clever ways to use a toilet and get in and out of bed.
- Your knees are stiff, painful, and after a time of just wishing it went away, you have now become a knee swelling manager.
- In your knee swelling managing kit is a list of remedies and over the counter products that are, at best, temporary solutions.
You have searched for answers and you pretty much get the same information on recommendations for managing knee swelling where ever you go.
- Rest, ICE, Compression, and Elevation and anti-inflammatory medications.
You have also purchased:
- Knee braces, ace bandages, various tapes, and knee sleeves
Despite all this effort, your knee swelling remains and you find yourself wrapping your knees with cool wraps as ice itself has become a drug for you, and, before any activity, you are taking pills as a form of preventative medicine.
Why is your knee always swollen?
You have swelling because your knee lives in a toxic, inflammatory environment and that toxic inflammation runs deeper than conservative anti-inflammatory care can handle
A joint that lives in constant inflammation is a joint in erosion. Your knee is in a corrosive state where it is breaking down faster than your body can repair it. The inflammatory process is corrosive. This is why there is an urgency to shut down the inflammation to stop joint erosion. What many patients do not realize is that inflammation that is causing the swelling in your knee runs deep. Deeper than anti-inflammatory medications can handle in the long-term. This is why your knee is always swollen.
Research: Patients do not know how bad their inflammation is, or how destructive it is to their knees
In March 2019, doctors at Brigham and Women’s Hospital, Harvard Medical School, Boston University School of Medicine, Weil Cornell Medicine, and the Mayo Clinic released their findings that basically said, patients do not know how bad their inflammation is. When a patient reports to the doctor that they have problems with swelling, the doctor should consider the problem worse than the patient is suggesting.
Listen to the learning points of the research published in the journal Arthritis Care & Research.(1)
- Synovitis is a prevalent feature in patients with knee osteoarthritis and meniscal tear and is associated with pain and cartilage damage.
- The researchers analyzed data from 276 patients. The patients self-reported their swelling episodes.
- Twenty-five percent of patients reported no swelling,
- 40% of patients reported had intermittent swelling,
- and 36% of patients reported had constant swelling.
When these patients had an MRI. The MRI found much more swelling than the patients reported. The conclusion of this study urged doctors to use caution against using patient-reported swelling as a proxy of inflammation manifesting as effusion-synovitis. In other words, the swelling is worse than the patients think it is. Simply, the knee is worse than they think it is.
What does 18 months of continued inflammation do when you have a meniscus tear?
Early in January 2019, the same research team published in the journal Arthritis & rheumatology (2) a study of 221 patients with knee osteoarthritis and meniscal tear. They examined these patients over a time period of 18 months.
- effusion-synovitis (swelling) was persistently minimal in 45.3% and persistently extensive in 21.3% of the patients.
- The remaining 33.5% of the patients had minimal synovitis on one occasion and extensive synovitis on the other.
- Patients with extensive effusion-synovitis at baseline (a lot of swelling) persistently extensive effusion-synovitis (continued extensive swelling) had a significantly increased risk of progression of cartilage damage depth. (A bigger hole in the cartilage or commonly the greater the risk of progression to “bone on bone,” within the 18 month study period).
Many of you will be reading this article because you are looking for ways to shut down your knee inflammation and swelling. It is hard because the problem is much more difficult than just swelling.
We see many patients who come in with worsening symptoms in their knee. Swelling has now simply become part of a terrible trio
- Constant swelling
- Pain and stiffness
- Instability and the knee gives way
These problems are getting worse DESPITE YEARS of medications.
When we see a patient in our clinics with knee swelling, we says, “what have you been taking for this?”
Typically the first line of treatment will include the use of anti-inflammatory drugs. The list includes many familiar names, medications you may already be on as well.
- Most common : aspirin, ibuprofen (Motrin, Advil), naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
- Prescriptions: celecoxib, diclofenac indomethacin, oxaprozin (Daypro), piroxicam (Feldene)
Why anti-inflammatories have not worked for you?
NSAID-resistant ongoing osteoarthritis pain
We then ask the patient if these anti-inflammatories were helpful. They usually reply: “At first they worked great, then I had to take higher doses.” We may then look at their swollen knee in the office and say: “They do not look like they are working today.”
Not only not working, making things worse:
Obviously, anti-inflammatory medication is designed to reduce pain and pressure produced by inflammation. In our article When Non-Steroidal Anti-Inflammatories (NSAIDs) make pain worse, we cite research against the use of NSAIDs. This research suggests:
- Stopping NSAIDs usage is seen as a way to help patients avoid joint replacement surgery and worsening pain
- The reason a joint replacement is recommended is because NSAIDs do not work. In fact, NSAIDs usage accelerated the pain that led to joint replacement recommendation.
- NSAIDs a false sense of healing makes things worse. Now research suggests that NSAIDs can be addictive
A study from the University of New England, published in the Journal of Pain, (3) supports this idea that NSAIDs’ failure to help a patient with toxic inflammation is a primary cause of knee replacement.
- From the research: “Difficulty in managing advanced osteoarthritis pain often results in joint replacement therapy. Improved understanding of mechanisms driving NSAID-resistant ongoing osteoarthritis pain might facilitate development of alternatives to joint replacement therapy.”
Please note the keywords: NSAID-resistant ongoing osteoarthritis pain
- This research is from doctors at Maastricht University Medical Centre and Boston University. In this study published in the journal, Public Library of Science One (4) is a discussion of the NSAID COX-2 inhibitor. (COX or cyclooxygenase, are two enzymes (COX-1 and COX 2) that promote inflammation).
The price for shutting off the inflammation?
- COX inhibitors shut off inflammation and directly cause suppression of cartilage cell growth and natural repair of articular cartilage growth.
NSAIDS prevent your knee from healing.
You may be recommended a cortisone injection
Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Some people do benefit from cortisone in the short-term – the evidence however points to cortisone causing more problems than it helps.
In our article Alternatives to Cortisone, we discuss some of this research including a new study from October 2019 which suggests cortisone leads to the greater need for knee or hip replacement.
- Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.
- This study was published by doctors from Tufts Medical Center in Boston and published in the Journal of the American Medical Association, (JAMA) (5)
- Cortisone disrupts and hurts stem cells
- This was a study published by the Mayo Clinic. (6) The research suggests that cortisone may hinder the native stem cells in cartilage. (Mesenchymal stem cells (MSCs) are the building blocks of cartilage other musculoskeletal tissue.) Cortisone threatens their innate regenerative capacity in exchange for temporary analgesia.
- In the International Journal of Clinical Rheumatology, (7) researchers wrote: “Corticosteroid therapy, as well as NSAIDs, can lead to destruction of cartilage, suggesting that a positive effect on joint pain may also be associated with accelerated joint destruction, which is an extremely important factor in a chronic, long-term condition such as osteoarthritis.”
Why RICE and ICE is not the answer
You may be recommended to the use of ice to reduce the swelling. For many athletes, a doctor’s recommendation of the RICE protocol for healing their sports related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism from a surprising source, the doctor who created the RICE treatment guidelines, Gabe Mirkin, MD.
In a recent article on his own website, Dr. Mirkin admits that both ice and rest (key components of RICE) may delay healing. This insight comes nearly 40 years after Dr. Mirkin authored the The Sportsmedicine Book (1978), where he coined the acronym RICE for the 4 elements which became the standard of care in treating soft tissue injuries- Rest, Ice, Compression and Elevation. Coaches, physicians, physical therapists and the lay public have recommended and followed the “RICE” guidelines for decades, but as Mirkin states:
- “it now appears that both ice and complete rest may delay healing, instead of helping.”(8)
If all these treatments do not work, and the inflammation continues and causes damage to the knee, surgical removal of the inflamed synovial tissue, ultimately a knee replacement may be recommended.
- The synovial fluid is a thick gel-like liquid that helps cushion the knee and acts to absorb the daily impact of walking and running and stair climbing our knees are subjected to.
- The synovial membrane lines the joint capsule and helps maintain synovial fluid in joints.
- Inflammation of the synovial membrane, synovitis, is found in both rheumatoid and osteoarthritis patients. It can also develop after knee surgery.
- Doctors use the synovial fluid as a means to understand the inflammatory environment of the knee.
To understand your inflammation is to understand that your knee is or has become unstable. But in is your unstable knee causing inflammation or is it inflammation causing your unstable knee? Something needs to get fixed.
Research is busy asking the question, what comes first, the inflammation or the degenerative knee disease? On the surface that seems pretty straight forward, inflammation and degeneration causes knee erosion. But not so fast –
Doctors at the University of Calgary, publishing in the medical journal Osteoarthritis and Cartilage, (9) suggest that knee joint instability leads to destructive alterations in the synovial membranes and cartilage. So in this research, the knee instability came first, then inflammation, then osteoarthritis.
Therefore to treat synovial inflammation – you must treat knee instability
Their research conclusion was that knee joint instability may promote an inflammatory intra-articular milieu (a diseased joint environment), thereby contributing to the development of osteoarthritis.
Getting rid of swelling and inflammation and degeneration requires a health professional familiar with using inflammation as a healing tool.
Above we said that a joint that lives in constant inflammation is a joint in a state of unrelenting erosion. Your knee is in a place where it is breaking down faster than your body can repair it. We are not just talking about a piece of the knee, like its just the cartilage, or it is just a tendon, or it is just a ligament, it is the whole knee spontaneously degenerating. This is why your whole knee is swelled up.
The focus of our treatment is the strengthening and repair of the knee ligaments. Why is this our focus?
If you want to get rid of chronic knee swelling you must have a treatment that repairs the entire knee. The ligaments are the structures that hold the entire knee together. This means to help repair a meniscus, you must strengthen the ligaments. To heal cartilage damage, you must treat the ligaments. To prevent recurrence of Baker’s Cyst, you must treat the ligaments. To prevent continued knee degeneration from the destructive forces of osteoarthritis, you must treat the ligaments with a treatment that correctly turns off the inflammation in such a way that beneficial inflammation, the inflammation process that repairs, is left behind to heal the damage.
The benefits of a holistic approach to treating the knee can be clearly seen in the definition of knee osteoarthritis:
Knee Osteoarthritis is destruction to the whole knee
- Knee swelling is the result of a a slow, progressive, degenerative disease that:
- destroys articular cartilage,
- causes destructive changes to the knee’s lubricating and protective synovial membrane,
- damages and causes the death of subchondral bone,
- causes weakness, damage, and laxity in the knee’s supporting ligaments and tendons,
- destroys and causes the death of the meniscus,
- and, in general, causes the degeneration of ligaments and menisci and causes destructive hypertrophy (enlargement or swelling) of the knee joint capsule.
Everything in the knee affects the ligaments and the ligaments affect everything in the knee. Undetected micro ligament damage causes swelling
Ligaments function primarily to maintain smooth joint motion, restrain excessive joint displacement, and provide stability across the knee joint. When the forces to which ligaments are subjected are too great (acute injury or degenerative failure caused by ligament laxity), failure occurs, resulting in drastic changes in the structure and physiology of the joint. In your knee, it is causing a lot of swelling and functional instability.
Above we discussed research that suggested that the patient did not realize how bad their knee was and that is why they had chronic swelling. Knee instability and swelling can be caused by mirco damage which causes instability that is not easily seen on MRI and is difficult to determine in a knee examination? Why because when the whole knee is in failure, it is hard to see the little things. Like micro tearing of the knee ligaments. One thing is easy to see however, that is the result of micro ligament damage also referred to as ligament laxity.
In this video, Ross Hauser, MD explains a Prolotherapy knee treatment as performed at our Caring Medical clinics. This is not typical of the way treatment may be performed in other doctor’s offices.
Video learning and demonstrated points:
- In this video, Ross Hauser, MD is seen demonstrating intra-articular (inside the knee) as well as injections surrounding the outside of the knee.
- The knee’s medial joint line here where the medial collateral ligament is.
- The pes anserine tendon
- The medial patellar retinaculum tendon
- The distal quadriceps attachments
- The lateral joint line where the lateral collateral ligament is located.
- The attachment of the iliotibial band
- The capsular knee ligament attachments
Comprehensive Prolotherapy for problems of knee instability and wear and tear and bone on bone
Repetitive inflammation as an anti-inflammatory
Comprehensive Prolotherapy is an injection technique that uses a simple sugar, dextrose, and in some cases, it is combined with Platelet Rich Plasma Therapy (blood platelets) to address damage and micro tearing of the ligaments or soft tissue in the knee. A series of injections are placed at the tender and weakened areas of the affected structures of the knee. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction.
The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, creating stronger ligaments and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the knee structures function normally rather than subluxing and moving out of place. When the knee functions normally, the pain and swelling goes away.
In published research in the Journal of Prolotherapy, we investigated the outcomes of patients receiving Prolotherapy treatment for unresolved, difficult to treat knee pain at a charity clinic in Illinois. Here are the bullet points of our research:
- The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with unresolved knee pain.
- Decreases in pain, stiffness, and crunching levels reached statistical significance with Prolotherapy.
- The percentage of patients with less knee pain was 95%, and 99% reported long term improvements in stiffness after Prolotherapy.
- Eighty-six percent of patients decreased their need for additional pain therapies, including medication usage by 90% or more, after Prolotherapy.
- Eighty-two percent showed an improvement in sleep.
- For those with depression and anxiety, 86% were less depressed and 82% were less anxious.
- In regard to activities of daily living, Prolotherapy improved walking ability in 84%, athletic ability in 76%, and dependency on another person in 75% of patients treated.
- Of the patients treated with the Hackett-Hemwall technique of dextrose Prolotherapy, 95% felt an overall improvement in their quality of life.
- Ninety-four percent of patients noted their improvement in overall disability has mostly continued since their last treatment.
Synovial fluid accumulated in the bursae around the knee joint
Doctors in Taiwan publishing their study in the medical journal Experimental gerontology (10) examined the effects of Platelet Rich Plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis. Here is their research summary:
- Patients with knee osteoarthritis are often complicated with joint soreness, swelling, weakness, and pain. These complaints are often caused by the excessive amount of synovial fluid accumulated in the bursae around the knee joint.
- They examined the effectiveness of platelet rich plasma in treating patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis.
- Twenty-four elderly patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis were recruited.
- Aspiration of the synovial fluid was performed under ultrasound followed by subsequent PRP injections.
- Three monthly PRP injections were performed to the affected knees for a total of 3 months.
- Approximately after the 2nd PRP injection, significant decreases in synovial fluid total protein concentrations and volumes (signifying a decrease in inflammation), and Lequesne index values (this is a value given to measure the severity of knee osteoarthritis) were observed.
- Therefore, at least two monthly PRP injections may be beneficial for treating patients with minor to moderate knee osteoarthritis combined with supra-patellar bursitis.
Do you have questions about Synovial inflammation of the knee? You can get help and information from our Caring Medical staff
1 MacFarlane LA, Yang H, Collins JE, Guermazi A, Mandl LA, Levy BA, Marx RG, Safran‐Norton CE, Losina E, Katz JN, MeTeOR Investigator Group. Relationship between patient‐reported swelling and MRI‐defined effusion‐synovitis in patients with meniscus tears and knee osteoarthritis. Arthritis care & research. 2018 May 4. [Google Scholar]
2 MacFarlane LA, Yang H, Collins JE, Jarraya M, Guermazi A, Mandl LA, Martin SD, Wright J, Losina E, Katz JN, MeTeOR Investigator Group. Association of Changes in Effusion‐Synovitis With Progression of Cartilage Damage Over Eighteen Months in Patients With Osteoarthritis and Meniscal Tear. Arthritis & Rheumatology. 2019 Jan;71(1):73-81. [Google Scholar]
3 Havelin J, Imbert I, Cormier J, Allen J, Porreca F, King T. Central sensitization and neuropathic features of ongoing pain in a rat model of advanced osteoarthritis. The Journal of Pain. 2016 Mar 1;17(3):374-82. [Google Scholar]
4. Caron MM, Emans PJ, Sanen K, Surtel DA, Cremers A, Ophelders D, van Rhijn LW, Welting TJ. The role of prostaglandins and COX-enzymes in chondrogenic differentiation of ATDC5 progenitor cells. PloS one. 2016 Apr 6;11(4):e0153162.[Google Scholar]
5 McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee OsteoarthritisA Randomized Clinical Trial. JAMA. 2017;317(19):1967-1975. [Google Scholar]
6 Wyles CC, Houdek MT, Wyles SP, Wagner ER, Behfar A, Sierra RJ. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clinical Orthopaedics and Related Research®. 2015 Mar 1;473(3):1155-64. [Google Scholar]
7 Sofat N. Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Rheumatol. Apr 2014; 9(2): 197–276. [Google Scholar]
8 Mirkin G. Why Ice Delays Recovery. March 16, 2014.
9 Egloff C, Hart DA, Hewitt C, Vavken P, Valderrabano V, Herzog W.Joint instability leads to long-term alterations to knee synovium and osteoarthritis in a rabbit model. Osteoarthritis Cartilage. 2016 Jun;24(6):1054-60.[Google Scholar]
10 Chen CPC, Cheng CH, Hsu CC, Lin HC, Tsai YR, Chen JL. The influence of platelet rich plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis. Exp Gerontol. 2017 Apr 20;93:68-72.[Google Scholar]