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 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 and 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.
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.
Discussion points of this article:
- Why is your knee always swollen?
- Fluid on the knee or in the knee drowns cartilage and meniscus cells and leads to bone on bone knees.
- Why nothing is helping your knee swelling.
- Chronic knee swelling is a symptom of developing and worsening knee osteoarthritis.
- Understanding that getting rid of chronic knee swelling is a matter of addressing the problem of degenerative knee disease.
- Knee swelling causes bone on bone knees.
- Research: Patients do not know how bad their inflammation is, or how destructive it is to their knees.
- “The doctor should consider the problem worse than the patient is suggesting.”
- A villain in all this, the Synovial macrophages (the stuff of inflammation) eating away at your knee.
- What do 18 months of continued inflammation and swelling us doing to your knee when you have a meniscus tear?
- Many of you will be reading this article because you are looking for ways to shut down your knee inflammation and swelling.
- These problems are getting worse DESPITE YEARS of medications.
- Why anti-inflammatories have not worked for you? NSAID-resistant ongoing osteoarthritis pain.
- You are told to have a cortisone injection.
- Your doctor may not want to give you cortisone if knee replacement is seen as ultimately your only answer.
- If you have a lot of swelling hyaluronic acid is really not going to help?
- Why RICE and ICE are not the answer.
- The problems of excess weight and obesity cause more inflammation.
- When all these treatments do not work, and the inflammation continues, surgical removal of the inflamed synovial tissue, and ultimately a knee replacement may be recommended.
- Is it your unstable knee causing inflammation or is it inflammation causing your unstable knee? Something needs to get fixed.
- To treat synovial inflammation – you must treat knee instability.
- Getting rid of swelling and inflammation and degeneration requires a health professional familiar with using inflammation as a healing tool.
- Everything in the knee affects the ligaments and the ligaments affect everything in the knee. Undetected micro ligament damage causes swelling.
- Synovial fluid accumulated in the bursae around the knee joint.
- Injection treatments.
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?
- 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.
- The swelling is a toxic soup. It bathes your knee in a constant inflammation that causes knee breakdown.
- As your knee is in a corrosive state where it is breaking down faster than your body can repair it you get caught in a cycle – breaking down causing swelling, swelling causing breakdown.
- The inflammatory process is corrosive. This is why there is an urgency to shut down the inflammation to stop knee destruction.
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.
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:
- Many patients tell us that their other health care providers and doctors dismiss or ignore their complaints of knee swelling. However, as research suggests, such as the research examined in this article, is that chronic knee swelling signifies the early development of osteoarthritis.
- The reason the knee is swelling relates to the strength or integrity or lack thereof of the soft tissue around the knee. So the knee swelling can be coming from knee ligament injury or instability. Your body, in an attempt to provide stability for the unstable knee, will swell the knee as a protective mechanism to provide stability to the need temporarily. It should be temporary. Your body is swelling the knee until healing of an injury can take place. The fluid fills the knee to also prevent excessive movement to accelerate healing. When the injury is healed the swelling goes away.
- If you do a job that is very physically demanding, you are on your feet all day, you climb ladders or steps, etc, that is a lot of strain to be putting on your knees and your body does the best it can to provide the swelling necessary to keep your knee together. The problem is chronic swelling is causing a rapid degeneration in the knee.
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:
- “. . . our results suggest that inflammation of the synovium, which occurs prior to cartilage degradation, is an early event during osteoarthritis initiation and progression. ”
- Note: Inflammation comes before cartilage breakdown. Inflammation, therefore, causes bone on bone, not the other way around.
- ” inflammatory and destructive responses in the pathogenesis of osteoarthritis are largely dependent on synovial cells, which produce proinflammatory cytokines such as IL-1β and TNF-α, and therefore have comprehensive effects on the other parts in the joint and contribute to cartilage degradation, synovial hyperplasia, subchondral sclerosis, and osteoarthritis pain.”
- Note: Inflammation of the knee synovial membrane is a toxic soup of pro-inflammatory factors. When your knee lives in a toxic soup, it is in a degenerating state.
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)
- 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 having intermittent swelling,
- and 36% of patients reported having 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.
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.
- 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.
We see many patients who come in with worsening symptoms in their knees. The 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 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.
- 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 the pain worse, we cite research against the use of NSAIDs. This research suggests:
- Stopping NSAID usage is seen as a way to help patients avoid joint replacement surgery and worsening pain
- The reason a joint replacement is recommended is that NSAIDs do not work. In fact, NSAID usage accelerated the pain that led to joint replacement recommendations.
- NSAIDs give a false sense of healing, making things worse. Now research suggests that NSAIDs can be addictive.
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.
- 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 the 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. This study published in the journal, Public Library of Science One (7) 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 are told to have a cortisone injection
In this video
- The difference between Prolotherapy and Cortisone is extensive.
- Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injection and these injections are no longer effective for them.
- Cortisone has been shown, in many studies, to accelerate degenerative osteoarthritis through cartilage breakdown.
- 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. Again, while 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.
- In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide (a synthetic corticosteroid medication) every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?” Writing in the Journal of the American Medical Association, (JAMA) (8) they published their answer:
- “Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.“
- In the International Journal of Clinical Rheumatology, (9) researchers wrote: “Corticosteroid therapy, as well as NSAIDs, can lead to the 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.”
Cortisone disrupts and hurts native stem cells
- This was a study published by the Mayo Clinic. (10) 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.
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:
- “Existing data indicate that intra-articular corticosteroids in knee osteoarthritis provide short-term pain relief and functional improvement which may last from one to several weeks.
- At present, synovitis (inflammation) is the most important predictor of treatment response, and also a target for anti-inflammatory treatment for intra-articular corticosteroids.”
- Our explanatory note: If you have a lot of knee swelling, cortisone may be of benefit.
- “Nonetheless, identification of responder from non-responder patients is challenging because the inflammatory presentation of knee osteoarthritis is temporal and is not present at all stages of the knee osteoarthritis process. At present, patients with significant disability or advanced knee osteoarthritis who are non-responsive to standard therapy are considered for treatment with intra-articular corticosteroids. The inefficiency of intra-articular corticosteroids in these patients is predictable because, in these subgroups, synovitis alone is not the cause of pain, but structural changes, mechanical and anatomical factors, and even extraarticular factors are also responsible, thus suppression of synovial inflammation by using intra-articular corticosteroids is likely to provide short-term pain relief or no therapeutic benefit.
- Our explanatory note: Simply the study authors are saying when cortisone will likely not work.
- Cortisone may not work in people whose inflammation comes and goes on its own because the inflammation is a response to a problem and not THE problem. THE problem is the knee joint degenerative condition. Cortisone cannot repair this type of damage.
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.
- The 137 patients in this study received hyaluronic acid injection two times at 2-week intervals.
- Initially, all the patients were helped. However, the patients who had ultrasound detected suprapatellar effusion (knee swelling) had greatly reduced benefits from the injections.
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:
- “it now appears that both ice and complete rest may delay healing, instead of helping.”(13)
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:
- “Being overweight or obese was significantly associated with a greater prevalence and severity of synovial inflammation imaging biomarkers. Substantial reproducibility and high correlation with knee structural, cartilage compositional degeneration, and pain scores validate the synovial inflammation biomarkers used in this study.”
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.
- 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 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
- Knee swelling is the result of 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 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:
- 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 an 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 (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:
- 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.
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.
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 Kennedy A, Fearon U, Veale DJ, Godson C. Macrophages in synovial inflammation. Frontiers in Immunology. 2011 Oct 10;2:52. [Google Scholar]
4 Ebata T, Terkawi MA, Hamasaki M, Matsumae G, Onodera T, Aly MK, Yokota S, Alhasan H, Shimizu T, Takahashi D, Homan K. Flightless I is a catabolic factor of chondrocytes that promotes hypertrophy and cartilage degeneration in osteoarthritis. Iscience. 2021 May 24:102643. [Google Scholar]
5 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]
6 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]
7 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]
8 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]
9 Sofat N. Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Rheumatol. Apr 2014; 9(2): 197–276. [Google Scholar]
10 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]
11 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]
12 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]
13 Mirkin G. Why Ice Delays Recovery. March 16, 2014.
14 Nishigami T, Nakao S, Kondo H, Oda S, Mibu A. A pleasant sensation evoked by knee or hand icing influences the effect on pain intensity in patients after total knee arthroplasty: a prospective, randomized, cross-over study. Journal of pain research. 2019;12:3469. [Google Scholar]
15 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
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]
17 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]
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