Treating chronic knee swelling, knee synovitis and inflammation without anti-inflammatory medication

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

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. Let’s start with:

You have searched for answers and you pretty much get the same information on recommendations for managing knee swelling where ever you go. 

You have also purchased:

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.

Knee Synovitis - Knee Swelling and Synovial inflammation

Discussion points of this article:

Why is your knee always swollen?

The simple answer to why is your knee is always swollen is because it is in a constant state of injury. Your immune system is constantly sending fluids to help cushion your knee and repair damaged tissue and remove dead tissue. The problem is, the knee is beyond its ability to repair the damage in your knee and the fluids remain constant.

So then, why is your knee always swollen?

What are we seeing in this illustration?

This illustration demonstrates the progression of knee osteoarthritis from a small tear or injury to degenerative joint disease. In this example a simple ligament injury, such as the medial collateral ligament depicted here) is not resolved, the resulting joint instability that this small injury can cause is the complete breakdown of the knee joint. As we are demonstrating in this article, a small unrepaired injury can spontaneously lead to osteoarthritis through swelling and inflammation.

This illustration demonstrates the progression knee osteoarthritis from a small tear or injury to degenerative joint disease. In this example a simple ligament injury, such as the medial collateral ligament depicted here) is not resolved, the resulting joint instability that this small injury can cause cause the complete breakdown of the knee joint. As we are demonstrating in this article, a small unrepaired injury can spontaneously lead to osteoarthritis through swelling and inflammation.

What are we seeing in this image? Fluid on the knee or in the knee drowns cartilage and meniscus cells and leads to bone on bone knees.

In this image, we see cells that are drowning. How does this happen? Aren’t our knees protected by synovial fluid? Don’t our knees live in fluid? Isn’t 90% of our body made of water? So how do cells drown?

At the start of your chronic knee problems, you were at the development phase of knee instability caused by weakened or damaged knee ligaments. As your knee became more unstable and somewhat painful your body started to send extra fluids into the knee to act as a sort of brace and extra shock absorber. Your body needs a functioning knee so your body is trying to protect your knee. As you continue on with your job and activities and your knee becomes more of a problem, your body sends more fluid to the knee. Your body is trying to tell you something. Your knee is a problem.

As knee degeneration continues cracks start developing in the articular cartilage of the knee. That is the cartilage that wraps at the bottom of the thigh bone, the back of the patella, and the top of the shinbones. Cracks and tears also develop in the meniscus. Here you are on the way to bone on bone. But it can get worse.

The pressure is building up in your knee. Water pressure. The fluids in your knee are applying great force against the cartilage and soon the cracks in the cartilage become bigger, larger tears develop, the fluid is forced into cartilage. The cartilage is supposed to be surrounded by fluids, not infiltrated by fluids. The fluids rushing onto the cartilage drown the cartilage cells. Accelerated cartilage loss is now occurring.

Why nothing is helping your knee swelling

There may be two reasons that you are reading this article. You did a casual search to see what you can do for your recent knee swelling event, perhaps you worked the long shift in the warehouse, decided to play 27 holes instead of 18, or did something to aggravate your knee beyond normal everyday function. Then you may have landed here because your knee swelling has been going on for years and you “have tried everything.”

Let’s see some stories from the emails we get from people who have “tried everything.”

I want to return to activities without pain and swelling and tightness and sleep without pain.

Here is a story, probably sounds like many of yours: I want to return to activities without pain and swelling and tightness and sleep without pain. My right knee has been causing me pain for the last five years. It all started with some minor sprains and tears. First was to MCL, then the meniscus had a small tear. I had an MRI and X-rays and the surgeon recommended I get a cortisone shot before considering arthroscopic surgery. The surgery is to clean up some debris.

The cortisone injection did not help. I was prescribed physical therapy which made my knee worse. I was not sleeping so I scheduled the surgery. I am waiting for the surgery now.

Generally, speaking what can be done for someone like this? More ice and anti-inflammatories? The cortisone did not work so it is not a problem of inflammation. The physical therapy did not help so it was not a matter of “working it out” or muscle strength. There is some type of damage in there beyond cleaning up some debris seen on an MRI. Is surgery needed? Are non-surgical treatments available?

The Baker’s cyst

I had a Baker’s cyst. It started three years ago and never went away. It eroded my knee to a point that I recently had to have a partial knee replacement. I am still suffering from the same symptoms of painful swelling and knee stiffness on a daily basis. My ortho doctor is talking about revision surgery.

Was it the Baker’s cyst that was eroding the knee or was the Baker’s cyst the result of something causing chronic inflammation? In this case, clearly, the surgery did not address the problem. For issues of Baker’s cysts and non-surgical options please see our article Baker’s cyst treatments.

Chronic knee swelling is developing and worsening knee osteoarthritis

In this video Danielle R. Steilen-Matias, MMS, PA-C offers a brief summary of the constant degenerative process going on in your knee that shows itself every day to you as swelling.

Summary and learning points:

Understanding that getting rid of chronic knee swelling is a matter of addressing the problem of degenerative knee disease.

Did the inflammation cause the swelling or did the swelling cause the inflammation? This is not a trick on words or some cute wordplay. Medical researchers in China teamed with doctors at  Rush University Medical Center and Drexel University to publish a January 2020 study (1)  in which they suggest that synovitis, or inflammation of the knee’s synovial membrane, precedes (comes before the erosion of the knee) and is associated with (the development of ) osteoarthritis.  What the researchers suggest is that when you have a chronic or acute knee injury, enough to cause chronic or acute inflammation, osteoarthritis progression begins spontaneously. What does that mean? You twist your knee. Your knee swells. Osteoarthritis is occurring right before your eyes. The swelling needs to be addressed.

Inflammation comes before cartilage breakdown. Inflammation, therefore, causes bone on bone, not the other way around. In other words, knee swelling causes bone on bone knees.

Here is what this paper said:

Research: Patients do not know how bad their inflammation is, or how destructive it is to their knees.

This is really something that is hard to imagine. The patient does not know how bad swelling is for their knee. Knee osteoarthritis and the eventual development of bone on bone knees do not usually happen overnight. We say usually because there is the phenomenon of rapidly accelerated knee osteoarthritis where a patient can go from stage 1 to stage 4 osteoarthritis in a matter of months or a few years. So even in this rapid stage, bone on bone does not occur overnight. As this is a gradual progression it is easy to stay with the same management routine day after day, month after month, year after year of painkillers, anti-inflammatories, and knee braces. You know all the while your knees are getting worse but you need to work or be a caregiver or do the things you need to do so you manage your knees on a daily “as needed” basis. On a daily basis, unless there is an acute event, it is difficult to see how your knees are moving forward to a degenerative disease requiring knee replacement.

Research: Cancer drug that blocks tumor growth may block runaway knee inflammation

Let’s look at a January 2023 paper published in the Journal of orthopaedic surgery and research.(18) In this paper doctors tested a hypothesis that blockade of vascular endothelial growth factor (VEGF) suppresses degenerative changes in articular cartilage from patients with knee osteoarthritis. This will help understand the confusion your own body has in trying to figure out how to deal with your knee inflammation. In this article vascular endothelial growth factor, a kind of Jekyll/Hyde aspect of healing is discussed as well as cancer tumor growth.

The presence of high vascular endothelial growth factor (VEGF) levels in the blood may be a clue that cancer may be present. Vascular endothelial growth factor (VEGF) helps create new blood vessels. In cancer patients the tumor creates an environment where it can grow but it requires more nutrients to do it. One way the tumor gets more nutrients is to create chemical messages to trick the body into creating new blood vessels and bring the nutrients to it.

Bevacizumab, brand name Avastin, is a drug given to cancer patients to stop this blood vessel expansion. Vascular endothelial growth factor (VEGF) is also seen as a dual personality in knee osteoarthritis. The same way cancer calls for blood vessel expansion, so does a knee with cartilage breakdown. The knee is calling for oxygen and nutrients to help breakdown disease tissue and build new tissue. The problems is when too many blood vessels are made and too much circulation gets into the knee. This, among many other factors, is a cause of knee inflammation, or better understood as runaway knee inflammation.

In this paper, in laboratory testing, Bevacizumab was seen to inhibit catabolic reactions (stopped tissue breakdown) and stimulates anabolic function in articular cartilage, suggesting a protective effect on articular cartilage from osteoarthritis progression.

What does this all mean? Simply, symptom relief is obtained by stopping inflammation and breakdown of the knee. In the case of Bevacizumab, this would allow for stimulation of articular repair.  Most studies on Bevacizumab in the treatment of osteoarthritis are animal and laboratory studies. More research is being conducted.

“the doctor should consider the problem worse than the patient is suggesting.”

Getting back to the idea that the patient does not know how bad it is. 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. (2)

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.

A villain in all this, the Synovial macrophages eating away at your knee

First, let’s identify what Synovial macrophages are. A paper in the journal Frontiers in Immunology (3) describes them this way: “Synovial macrophages are one of the resident cell types in synovial tissue and while they remain relatively quiescent in the healthy joint, they become activated in the inflamed joint and, along with infiltrating monocytes/macrophages, regulate the secretion of pro-inflammatory cytokines and enzymes involved in driving the inflammatory response and joint destruction.” Probably what you got the most out of this paragraph is “driving the inflammatory response and joint destruction.”

How are the synovial macrophages doing it? By bloating chondrocytes and making them puke up corrosive substances in your knee

Here is a May 2021 study in the journal iScience (4) that explains what is happening in your knee: “Synovial macrophages that are activated by cartilage fragments initiate synovitis, a condition that promotes hypertrophic (bloating) changes in chondrocytes (cartilage cells) leading to cartilage degeneration in osteoarthritis. . . Stimulated macrophages promoted hypertrophic changes in chondrocytes resulting in the production of matrix-degrading enzymes of cartilage.” So the chondrocytes become bloated with matrix-degrading enzymes of cartilage and puke them out in the knee.

What do 18 months of continued inflammation and swelling us doing to your knee when you have a meniscus tear?

Early in January 2019, the same research team published in the journal Arthritis & Rheumatology (5) a study of 221 patients with knee osteoarthritis and meniscal tear. They examined these patients over a time period of 18 months.

Many of you will be reading this article because you are looking for ways to shut down your knee inflammation and swelling.

We see many patients who come in with worsening symptoms in their knees. The swelling has now simply become part of a terrible trio

These problems are getting worse DESPITE YEARS of medications.

When we see a patient in our clinic with knee swelling, we ask, “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.

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 the pain worse, we cite research against the use of NSAIDs. This research suggests:

A study from the University of New England, published in the Journal of Pain, (6) supports the idea that NSAIDs’ failure to help a patient with toxic inflammation is a primary cause of knee replacement.

Please note the keywords: NSAID-resistant ongoing osteoarthritis pain

The price for shutting off the inflammation?

NSAIDs prevent your knee from healing.

You are told to have a cortisone injection

In this video 

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.

Cortisone disrupts and hurts native stem cells

Your doctor may not want to give you cortisone if knee replacement is seen as ultimately your only answer.

We see many patients who tell us that they have gone to their doctors and have asked for “one more” cortisone injection because of the amount of pain and swelling that they were suffering from that day. You know that the call to the doctor’s office for an appointment usually comes on the day when your knee hurts worse. The doctor, to his/her credit in many cases, has declined to give his/her patient this “one more” cortisone shot because their concern is that if you get cortisone injections into your knee prior to surgery, you will have a greater risk of complications after the surgery. There is a lot of debate around this subject.

A December 2020 (11) study published in the medical journal Rheumatology gives this overview assessment of the debate surrounding the use of cortisone for a bone on bone knee. Here are the summary learning points:

We have a very extensive article: What are the different types of knee injections for bone on bone knees. That goes further in discussing Cortisone injections; Hyaluronic acid injections; Platelet Rich Plasma Therapy; Stem Cell Therapy; Amniotic, Cord Blood, and Placenta Tissue injections; Prolotherapy; Botox® injections into the knee, and Ozone therapy.

If you have a lot of swelling hyaluronic acid is really not going to help.

You have a lot of swelling and pressure in your knee because you have too much “water on the knee” or in reality too much synovial fluid. That is a simple explanation. Many people find relief when this fluid is drained. So will people find relief if more fluid is added? It seems counterproductive for knee pain relief. This is why there is a debate over the long-term effectiveness of hyaluronic acid injections for knee osteoarthritis.  We are only going to present one study here, please see our article: Research and reviews of Hyaluronic injections for Knee Osteoarthritis for more on this topic.

Getting back to the question above – does injecting hyaluronic acid, putting more synovial type fluid in your knee, work when you already have an overabundance of this fluid? For some, the answer is yes it helps. For others, it does not help.

A January 2021 study in the medical journal Rheumatology (12) explains it. What the researchers in this study set out to do was to determine whether ultrasound-detected synovitis affects the therapeutic efficacy of hyaluronic acid injection for treating knee osteoarthritis.

Why RICE and ICE is not the answer

You may be recommended to use 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 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:

We have seen many patients who have become nearly addicted to icing. They treat ice as if it were a drug. Look at this interesting paper in the Journal of pain research. (14) It was published in December 2019. It describes icing a knee as a “pleasant sensation.” Let’s also point out that the patients who found the ice pleasant were newly knee-replaced patients. Further. If the knee did not respond in a pleasant way, then you could ice the patient’s hand.  This is from the paper:

“Cold therapy on the operated area after surgery is often used as an analgesic to reduce pain, swelling, and increase range of motion. However, evidence to support the results of cold therapy is still scarce and the mechanism underlying its effectiveness remains unclear.” In other words, does it work? How does it work? Is it all in the mind? To answer these questions the researchers investigated whether a pleasant sensation evoked by icing the treated knee or a site distant from the treated site (the hand) influenced the acute effect on pain intensity in patients who have undergone total knee arthroplasty (replacement).

A total of 37 patients with knee osteoarthritis underwent a total knee replacement. A cold pack was placed on the anterior surface of the treated knee and palm for 10 mins, respectively. The main primary outcomes were the intensity of knee pain during maximal passive knee flexion. The results showed that a pleasant sensation evoked by knee or hand icing influenced the effect on pain intensity during maximal knee flexion in patients after total knee replacement. Even if knee icing has no effect on pain and evokes no pleasant sensation, it may be worthwhile to conduct hand icing to reduce pain.

Certainly icing the hand would cut down on the detrimental effects of icing the knee.

The problems of excess weight and obesity causes more inflammation

When we suggest to the patient that their knee can benefit from weight loss, we typically hear, “I know, I know,” or “I have been trying.” These are the typical responses of someone who has tried to lose weight and is tired of being lectured. Weight gain, like knee osteoarthritis, is a slow methodical problem that cannot be made to go away overnight. To lose weight you must find the inner motivation to do so. Maybe research can help.

In July 2020, researchers writing in the medical journal Skeletal Radiology (15) looked at three patient groups. All the patients had knee osteoarthritis. The three groups were: people with normal weight; people who were overweight; people who were obese. What they were looking for was a relationship between excess weight and increases knee inflammation. Here are the results:

What does all this mean? The more weight, the more inflammation, the more pain, the greater the need for medication, the greater the knee pain, the greater the eventual need for knee replacement.

If you want to cover this aspect of your knee inflammation problems further, please see our article: What is the best anti-inflammatory medicine? It may be weight loss

If all these treatments do not work, and the inflammation continues and causes damage to the knee, surgical removal of the inflamed synovial tissue, and ultimately a knee replacement may be recommended.

To understand your inflammation is to understand that your knee is or has become unstable. But 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 straightforward, inflammation and degeneration cause knee erosion. But not so fast –

Doctors at the University of Calgary, publishing in the medical journal Osteoarthritis and Cartilage, (16) 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 it’s 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 the recurrence of a 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 

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 microdamage 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.

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 go 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:

Synovial fluid accumulated in the bursae around the knee joint

Doctors in Taiwan publishing their study in the medical journal Experimental Gerontology (17) 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:

Questions about our treatments?

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References: 

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16 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]
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18 Sotozawa M, Kumagai K, Ishikawa K, Yamada S, Inoue Y, Inaba Y. Bevacizumab suppressed degenerative changes in articular cartilage explants from patients with osteoarthritis of the knee. J Orthop Surg Res. 2023 Jan 10;18(1):25. doi: 10.1186/s13018-023-03512-2. PMID: 36627659.

This article was updated January 11, 2023

 

 

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