What to do about knee pain being caused by your unmanaged or uncontrolled Type 2 diabetes

Ross Hauser, MD

In this article, we will explore the challenges faced by people with knee pain and unmanaged or uncontrolled type 2 diabetes. If you are someone suffering from type 2 diabetes and knee pain, one challenge you may be facing is your reduced ability to heal the damage in your joints and avoid knee replacement. If you are recommended to knee replacement, complication risk in Type 2 diabetes patients is another great concern.

Mediations, diabetes and knee pain

Here is a general description of what patients who have knee pain and type 2 diabetes tell us when they first visit us.

I have been on metformin for a couple of years, I am now on statins and other medications to help control my blood glucose and my cholesterol levels. I have been having a lot of knee pain lately. One of my doctors is looking into my statins prescriptions. My doctor thinks my statins may be the cause of my knee pain. I have been told that I need to change my diet
(For more on knee pain and statins please see my article My doctor says that my knee pain is being made worse by my elevated cholesterol).

There is nothing earth breaking here, in fact, it is a routine description that many patients offer. A patient has knee pain and is on lots of medications. They have high glucose and high cholesterol levels. The recommendations to manage this knee pain range from more medications to change in diet and lifestyle. Change and increasing medication is easy, there is nothing more to it than getting your new prescriptions filled. Change in diet and lifestyle is hard. We are going to review some research now that may inspire you to take the more difficult path of lifestyle change.

We also invite you to read our article: Your bad diet and weight is destroying your knees and will send you to a nursing home

When taking a lot of pills makes knee pain worse in type 2 diabetes patients

Many patients that we see in our offices describe a long medical history filled with conservative care treatments for their knee pain. As many patients put it; “I take a lot of pills.”

In August 2019, a multi-national team of researchers published troubling findings in how pain management of patients with type 2 diabetes and osteoarthritis could lead to serious side effect concerns. What the researchers discussed is the taking of “lots of pills.” This research was published in the journal Seminars in Arthritis and Rheumatism. (1)

“Evidence is mounting for safety concerns”

“Type 2 Diabetes mellitus has a pathogenic effect on osteoarthritis through 2 major pathways involving oxidative stress and low-grade chronic inflammation resulting from chronic hyperglycemia and insulin resistance. Type 2 Diabetes mellitus is a risk factor for osteoarthritis progression and has a negative impact on (joint replacement) outcomes. Evidence is mounting for safety concerns with some of the most frequently prescribed anti-osteoarthritis medications, including paracetamol (Tylenol), non-steroidal anti-inflammatory drugs, and corticosteroid injections.”

The reason patients are in our office seeking options for the treatment of their knee pain is that they have concerns about knee replacement and their diabetes problems. Further, if they have diabetes, they will most likely have problems with high blood pressure, being overweight, high cholesterol, fatigue, and muscle pain. The muscle pain of course not only comes from spasms caused by damaged joints, but they can also come from medications the patient is one to combat these problems. When you add these problems on top of the safety and health concerns expressed by the researchers above, these people are not in a good place for healing.

Type 2 diabetes can create a toxic non-healing joint environment and cause joint damage and joint erosion by itself, no wear and tear necessary

Above I briefly outlined some of the many challenges someone with diabetes and osteoarthritis can have. Let’s throw another challenge into this mix. The challenge that Type 2 diabetes has been described as an independent risk factor for osteoarthritis. This means type 2 diabetes can create a toxic non-healing joint environment and cause joint damage and joint erosion by itself, no wear and tear necessary. This also means resting or “staying off your knee,” will not be beneficial in reversing or even stopping continued knee damage. The reality is one day you will most likely be sent to knee replacement surgery.

Getting rid of “sugar on the knee”

Here are highlights of a recent research paper from doctors at Sorbonne University in Paris writing in Diabetes Research and Clinical Practice. (2) In this research, the doctors examined how type 2 diabetes causes knee pain.

Point number 1:

The development of knee osteoarthritis IS associated with obesity and metabolic syndrome. Simply, the excess weight and diabetes are destroying your knee.

Point number 2:

The negative impact of diabetes on joints could be explained by the induction of oxidative stress and pro-inflammatory cytokines (lots of inflammation), advanced age and accumulation and exposure to chronic high glucose concentrations.
In other words:
- What these researchers are saying is that your knee is swimming in a toxic soup of inflammation caused by oxidant stress. Look down at your knees. The swelling you see, that is the toxic soup that may be caused by chronic high glucose concentration. In simplest terms – you have “sugar on the knee.”

Point number 3: chronic low-grade inflammation that is constantly eating at your knee.

Insulin resistance might also impair joint tissue because of local insulin resistance of diabetic synovial membrane but also by the systemic low-grade inflammation state related to obesity and insulin-resistant state.
- In other words Insulin resistance, this is where you cannot produce enough insulin to manage your sugar levels and in your swollen knee, this not only leads to inflammation as we just mentioned but also a chronic low-grade inflammation that is constantly eating at your knee.
- Please see my article: Is weight loss the best anti-inflammatory medication?

As you can see the impact of type 2 diabetes on degenerative joint disease is multi-factorial and a battle your body fights on many fronts.

Look down at your knees. The swelling you see, that is the toxic soup that may be caused by chronic high glucose concentration. In simplest terms – you have “sugar on the knee.”

Type 2 diabetes prevents bone repair which damages your cartilage

All the factors mentioned in the research above significantly impacts how your knee repairs itself from wear and tear damage.

In the medical journal Bone Research, (3) a team of researchers investigated Type 2 diabetes’ association with knee osteoarthritis. They found that patients with type 2 diabetes have unique abnormal subchondral bone remodeling and microstructural and mechanical knee impairments which caused greater cartilage degradation.

In other words, the type 2 diabetes prevents proper bone remodeling/healing. This abnormal bone compromises the structure of the articular cartilage of the knee. Type 2 diabetes accelerates knee osteoarthritis. Type 2 diabetes is attacking the whole knee.
In other words, all the components of a recommendation to knee replacement are coming into play.

Type 2 diabetes and knee osteoarthritis increases fall risk

A December 2022 paper in the journal Medicine (4) investigated the main factors that contributed to falls in knee osteoarthritis patients. The researchers found that the people with knee osteoarthritis who were less likely to fall, had good knee proprioception (the sensory function of the nerves of the knee communicated well with the central nervous system to, in simplest terms, prevent “missteps.”) They also had a good range of knee motion with minimal knee buckling and locking up factors.

However, patients with worse pain, less function and more disability as measure by standard Knee Injury and Osteoarthritis Outcome Score (KOOS), who also had fear of falls, low back pain, diabetes mellitus, and elevated Body Mass Index tended to have a higher or moderate risk of falls. Finally, diabetes mellitus and fear of falls were shown to be most strongly associated with fall risk.

The more you ignore your type 2 diabetes the greater the likelihood that you will need a knee replacement

An international team of researchers led by the University of California at San Francisco publishing in February 2018 in the Journal of Magnetic Resonance Imaging (4) found that not only did Diabetes type 2 accelerate knee osteoarthritis, the more unmanaged or severe the diabetes, the more severe the cartilage degeneration.

In other words, the more you ignore this or do not properly manage your type 2 diabetes, the greater the likelihood that you will need a knee replacement. Before you think knee replacement is a good solution, read on:

The problems with knee replacement complications and type 2 diabetes.

There is a lot of research into knee replacement complications. Those surrounding type 2 diabetes find complication rates higher because of many factors including the compromised ability of the patient’s bone to heal. This was noted in The Journal of arthroplasty by a leading team of Japanese medical university researchers who noted restricted knee range of motion and poorer functional recovery after total knee replacement.(5)

Doctors writing in Medical Science Monitor wrote in May 2017 that successful outcomes for patients with knee replacement and Diabetes Type 2 required close monitoring for deep vein thrombosis, preventing post-surgical infections, and monitoring heart and lung function.(6)

In November 2019, doctors at the University of Texas wrote in the Journal of diabetes research (7) that doctors should carefully consider knee replacement for type 2 diabetes patients as they are often older, have obesity and specific comorbidities predisposing to worse postoperative outcomes than people who get knee replacements who do not have type 2 diabetes. They suggest treatments that would limit osteoarthritis spread or treating diabetes, high blood pressure and obesity first before knee replacement.

For many doctors, this would mean prescribing more medications. This article is about more medications making knee pain worse, so now we have a patient stuck in a vicious cycle.

Prolotherapy injections and uncontrolled type 2 diabetes

Prolotherapy is a regenerative injection therapy where we inject a hypertonic dextrose (sugar) solution into the supportive structures in and around the knee. I know what you are saying, if I already have “sugar on the knee,” how will injecting dextrose (a simple sugar), help me? Won’t it make it worse?

Please see our very detailed article on to learn more about Prolotherapy and Knee Osteoarthritis.

Prolotherapy is an injection technique that stimulates growth factor cells that work to repair damaged joints.
Prolotherapy can be very helpful in patients with knee instability or hypermobility caused by damaged knee ligaments and tendons. Knee instability is a cause of knee osteoarthritis and degenerative wear and tear.

How does Prolotherapy work in your knees?

In a study that we cite, in other articles on our website, published in the prestigious international journal Therapeutic advances in musculoskeletal disease, doctors wrote of excellent patient outcomes in a study of Prolotherapy injections for with knee osteoarthritis (8).

Unfortunately, there were patients excluded from the study because of concerns over the likelihood of poor outcomes because of poorly controlled diabetes mellitus with fasting blood sugar greater than 11.1 mmol/L.
Another well-known study on the success of Prolotherapy treatments for knee osteoarthritis lead by our friend and colleague Dr. David Rabago, MD of the University of Wisconsin also excluded patients with uncontrolled diabetes mellitus defined as glycosylated hemoglobin (HbA1c levels) >7.5%). (9)

Poor blood glucose control and an elevated HbA1c increase the risk for poor healing, as well as the development of adult-onset diabetes and its associated health risks, which can lead to heart disease. Every day we treat patients with joint pain, arthritis, and sports injuries whose goal is to heal and return to their normal lives. High glucose levels compromise that goal and put them at risk for further diseases in the future.

Fortunately, we have worked with many patients over the years with type 2 diabetes and have helped them on their path to healing and a better dietary lifestyle.

Summary

We have been doing Prolotherapy for many years now, having started in January 1993. We have treated people with brittle diabetes, those on pumps, as well as many other diabetics (on oral pills and just one insulin/day). Likewise, we have treated people who are a little overweight to those who were very overweight.

So what happens when these people get Prolotherapy? For many, their pain goes away. Obesity, diabetes, and other medical conditions can slow the effects of Prolotherapy. If this occurs instead of the person needing three to six visits of Prolotherapy they may need six to ten visits. If they heal normally, they have a 75 to 82% chance of being cured of their pain.

Over the course of the last almost 30 years and having performed thousands of Prolotherapy sessions on diabetics we have found it very well tolerated. Most of the diabetics tell us that it raises their blood sugar only a mild amount (like 10-30 points). This is also for a short time (perhaps a few hours).

In regards to those who are very overweight, they do not need to loose weight for the Prolotherapy to help them. We would encourage them to lose weight because it would mean less stress on their joints. When there is less stress on the joints, they need less Prolotherapy. So if they want to need less Prolotherapy, then loose some weight.

For the person with the complicated medical condition, all we can say is that it would be best to get a comprehensive medical evaluation and treatment. The healthier you are the better you will heal from the Prolotherapy. You can still get Prolotherapy alone, but your healing may be slower.

Do you have questions about diabetes, joint repair, and Prolotherapy?

You can get help and information from our Caring Medical staff.

1 Veronese N, Cooper C, Reginster JY, Hochberg M, Branco J, Bruyère O, Chapurlat R, Al-Daghri N, Dennison E, Herrero-Beaumont G, Kaux JF. Type 2 diabetes mellitus and osteoarthritis. In Seminars in arthritis and rheumatism 2019 Jan 11. WB Saunders. [Google Scholar]
2 Courties A, Sellam J. Osteoarthritis and type 2 diabetes mellitus: What are the links?. diabetes research and clinical practice. 2016 Dec 31;122:198-206. [Google Scholar]
3 Chen Y, Huang YC, Yan CH, Chiu KY, Wei Q, Zhao J, Guo XE, Leung F, Lu WW. Abnormal subchondral bone remodeling and its association with articular cartilage degradation in knees of type 2 diabetes patients. Bone research. 2017 Nov 7;5:17034. [Google Scholar]
4 Rosadi R, Jankaew A, Wu PT, Kuo LC, Lin CF. Factors associated with falls in patients with knee osteoarthritis: A cross-sectional study. Medicine. 2022 Dec 2;101(48):e32146. [Google Scholar]

4 Chanchek N, Gersing AS, Schwaiger BJ, Nevitt MC, Neumann J, Joseph GB, Lane NE, Zarnowski J, Hofmann FC, Heilmeier U, Mcculloch CE. Association of diabetes mellitus and biochemical knee cartilage composition assessed by T2 relaxation time measurements: Data from the osteoarthritis initiative. Journal of Magnetic Resonance Imaging. 2018 Feb 1;47(2):380-90. [Google Scholar]
5 Wada O, Nagai K, Hiyama Y, Nitta S, Maruno H, Mizuno K. Diabetes is a risk factor for restricted range of motion and poor clinical outcome after total knee arthroplasty. The Journal of arthroplasty. 2016 Sep 1;31(9):1933-7. [Google Scholar]
6 Liu P, Liu J, Xia K, Chen L, Wu X. Clinical Outcome Evaluation of Primary Total Knee Arthroplasty in Patients with Diabetes Mellitus. Medical science monitor: international medical journal of experimental and clinical research. 2017;23:2198. [Google Scholar]
7 Na A, Jansky L, Gugala Z. Clinical Characteristics of Patients with Type 2 Diabetes Mellitus Receiving a Primary Total Knee or Hip Arthroplasty. Journal of Diabetes Research. 2019;2019. [Google Scholar]
8 Eslamian F, Amouzandeh B. Therapeutic effects of prolotherapy with intra-articular dextrose injection in patients with moderate knee osteoarthritis: a single-arm study with 6 months follow up. Ther Adv Musculoskelet Dis. 2015 Apr;7(2):35-44. [Google Scholar]
9 Rabago D, Zgierska A, Fortney L, Kijowski R, Mundt M, Ryan M, Grettie J, Patterson JJ. Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: results of a single-arm uncontrolled study with 1-year follow-up. Journal of Alternative and Complementary Medicine. 2012 Apr 1;18(4):408-14. [Google Scholar]
10 Rosadi R, Jankaew A, Wu PT, Kuo LC, Lin CF. Factors associated with falls in patients with knee osteoarthritis: A cross-sectional study. Medicine. 2022 Dec 2;101(48):e32146. [Google Scholar]

This article was lasted updated April 20, 2022

2597 (166)