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.

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.

Osteoarthritis progression begins spontaneously with a knee injury. Swelling is osteoarthritis happening before your eyes.

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 and is associated with 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.

Inflammation comes before cartilage breakdown. Inflammation, therefore, causes bone on bone, not the other way around.

Here is what they said:

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.

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.


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:

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

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.

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

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.

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.

What does 18 months of continued inflammation do to your knee when you have a meniscus tear?

Early in January 2019, the same research team published in the journal Arthritis & Rheumatology (3) 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, (4) 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 (9) 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 (10) 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:

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 (12) 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 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 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, (13) 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 (14) 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.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References: 

1 Liao L, Zhang S, Zhao L, Chang X, Han L, Huang J, Chen D. Acute Synovitis after Trauma Precedes and is Associated with Osteoarthritis Onset and Progression. Int J Biol Sci. 2020 Jan 1;16(6):970-80. [Google Scholar]
2 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]
3 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]
4 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]
5 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]
6 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 TrialJAMA. 2017;317(19):1967-1975. [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 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]
9 Heidari P, Heidari B, Babaei M. Efficacy and predictive factors of response to intra-articular corticosteroids in knee osteoarthritis. Reumatologia. 2020;58(6):424. [Google Scholar]
10 Wang CC, Wang CT, Tsai KL, Chou CL, Chao JK, Huang HY, Kao CL. Effect of ultrasound-detected synovitis on therapeutic efficacy of hyaluronic acid injection for symptomatic knee osteoarthritis. Rheumatology. 2021 Jan 25. [Google Scholar]
10 Mirkin G. Why Ice Delays Recovery. March 16, 2014.
12 Kanthawang T, Bodden J, Joseph GB, et al. Obese and overweight individuals have greater knee synovial inflammation and associated structural and cartilage compositional degeneration: data from the osteoarthritis initiative [published online ahead of print, 2020 Jul 23]. Skeletal Radiol. 2020;10.1007/s00256-020-03550-5. doi:10.1007/s00256-020-03550-5
13 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]
14 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]

This article was updated March 11, 2021

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