Doctors Specializing in Sports Medicine

John "Trey" Green, M.D. (UT Medicine, University Hospital) Click for information

Marc DeHart, M.D. (UT Medicine, University Hospital) Click for information

Philip M Jacobs, M.D. (UT Medicine, University Hospital) Click for information

All Orthopaedic Clinic Locations

MARC - UT Health San Antonio Click for information

Audie L. Murphy Memorial Verterans Hospital (VA) Click for information

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Texas Diabetes Institute Click for information

Mays Cancer Center at UT Health  Click for information

Ruthe B. Cowl Rehabilitation Center, Laredo, TX  Click for information

The Knee

 

 

front of a right knee

How the knee works

The knee is what is called a hinge joint. It is also classified as a synovial joint along with the ankle and elbow. It works to flex (bend) and extend (straighten) and also has a small amount of rotation.  The three bones that make up the knee are the femur (thighbone), tibia (shinbone) and patella (knee cap). Structures that support the knee include ligaments, tendons, meniscus and cartilage.

Ligaments

Ligaments are a dense connective tissue that connects bone to bone. They are fairly short in comparison to tendons, but very similar in what they are made of. Ligaments are tough and flexible and look like a white band or cable-like structure. To withstand forces that it takes from different directions a ligament is made of a weaving matrix of fibers.

The ligaments of the knee include cruciate (Latin word for “cross”) and collateral ligaments. The fibers of the anterior cruciate and posterior cruciate ligaments are wound in a spiral pattern to withstand the twisting and pulling of the knee. In contrast, the fibers of the medial collateral and lateral collateral ligaments pass more straight from bone to bone along the sides of the knee joint. The blood supply to the ligaments inside the knee (ACL and PCL) is fairly low, which affects the healing process of an injured ligament. Low blood supply can also increase the risk of rupture when the ligament is overstressed.

Causes  ^

Knee sprains may be caused by:

  • • Forced twisting of the knee
  • • Stopping suddenly while running
  • • Shifting your weight while running or skiing
  • • Landing awkwardly after jumping
  • • Blow to the outer or inner side of the knee
  • • Blow to the front of the knee while the knee is bent and the foot is firmly planted on the ground

Risk Factors  ^

2nd image front of a right knee

Factors that may increase your chance of developing a knee sprain include:

  • • Playing sports
  • • Poor coordination
  • • Poor balance
  • • Inadequate flexibility and strength in muscles and ligaments
  • • Loose joints

Symptoms  ^

Symptoms include:

  • • Pain in the knee
  • • Swelling, redness, warmth, or bruising around the knee
  • • Decreased range of motion in the knee
  • • Inability to stand on the affected leg
  • • Tenderness where the injured ligament attaches to a bone in the knee
  • • Swelling within the knee

Diagnosis  ^

You will be asked about your symptoms and how the injury occurred. The knee will be checked to see how stable the joint is and how severe the pain is.

Images may be taken of your bodily structures. This can be done with:

A minimally invasive procedure may be done to look inside of your knee. This can be done with arthroscopy.

CLICK HERE to make an appointment with an orthopedic surgeon.

Back of a right knee

ACUTE INJURIES TO THE KNEE

Anterior Cruciate Ligament (ACL) How it happens: A twisting injury involving the knee often causes the ACL to reach a maximum level of loading force and the ACL ruptures. Another way the ACL is torn is with an impact or a tackle to the outside of the knee while the leg is straight. Symptoms: patients hear a “pop” in their knee, knee giving way (instability), swelling hours after the injury, stiffness, pain, bruising.

 Posterior Cruciate Ligament (PCL)

How it happens: Usually tears when the front of the tibia is impacted with a large force like during a motor vehicle accident and the patient’s lower leg slams into the dashboard. 

Symptoms: knee giving way (instability), swelling hours after the injury, stiffness, pain, bruising. 

 Medial Collateral Ligament (MCL)

How it happens: With an impact or a tackle to the outside of the knee while the leg is straight. While the outside of the knee takes the brunt of the force, the inside of the knee joint gets very wide and the MCL fails. This is common in football, baseball and soccer. The MCL is also a ligament that can tear along with the injury that caused the ACL to tear.

Symptoms: tenderness on the inside of the knee, swelling

 Lateral Collateral Ligament (LCL)

How it happens: With an impact or a tackle to the inside of the knee while the leg is straight. While the inside of the knee takes the brunt of the force, the outside of the knee joint gets very wide and the LCL fails. This is common in football and soccer during a tackle. Symptoms: tenderness to the outside of the knee, swelling, stiffness  

Treatment includes:

Rest, Ice, Compression, and Elevation The RICE method may help reduce discomfort and swelling:

• Rest—Avoid putting any pressure on your knee by not walking on that leg.

• Ice—Apply ice or a cold pack to the knee to reduce pain and swelling.

• Compression—Wrap your knee in an elastic bandageto limit swelling and provide support.

• Elevation—Keep the injured knee raised above the level of your heart. This will help drain fluid and reduce swelling. Dr. Green examines a knee

Rehabilitation Exercises

Exercises may be advised to restore flexibility, range of motion, and strength. A referral to a physical therapist may be needed.

Surgery

Surgery may be needed if a ligament is torn completely.

 

Prevention 

To reduce the risk of knee sprains:

• Warm up and stretch before exercise. Cool down and stretch after exercise.

• Take a break from sports and exercise when you feel tired.

• Do exercises that strengthen the leg muscles.

• Learn the proper technique for sports and exercise. This will decrease stress on all muscles, ligaments, and tendons, including those around the knee. Also, wear the proper equipment.

• Ask your doctor if you should use a brace.

CLICK HERE to make an appointment with an orthopedic surgeon.

 

  Tendons

Tendons are thick bands of connective tissue that connect muscle to bone. Similar to ligaments, they are made of collagen and can withstand increased tension. Tendons are the reason a muscle can move the bones in our body when muscles contract.

 The tendons involved in the knee include the quadriceps tendon, the patella tendon, hamstring tendons, and the iliotibial band.

The quadriceps tendon connect the quadriceps muscle to the patella (kneecap) and provides the power for straightening the leg. The quadriceps muscle is a group of four muscles; from outside to inside they are vastus lateralis, vastus intermedius, vastus medialis with rectus femoris lying over top of vastus intermedius. A common injury in jumpers is a quadriceps tendon rupture. On an xray view of the side of the knee the patella would be lower than normal as it migrates down the front of the knee because of losing its attachment with the quadriceps muscle.

The patellar tendon is not actually a real tendon as it does not connect muscle to bone. The patellar tendon connect the patella to the front of the tibia (shinbone). It’s named a tendon because in a sense it is the continuation of the quadriceps tendon after the patella. This tendon is helpful in straightening the knee as well. The patellar tendon can rupture in jumpers as well with a hard landing. On an xray view of the side of the knee the patella would be higher than normal as it migrates up the front of the knee because of losing its attachment with the tibia (shinbone). This tendon can also rupture if the front of the knee is hit hard or a person falls and takes the impact on this tendon.

A common problem with this tendon is known as patellar tendonitis and is often seen in runners and jumpers. The tendon becomes very irritated and small tears occur in the tendon. As the tendon tries to heal itself, scar tissue may build up which can become painful.

The hamstrings tendon starts at the bottom of the pelvis and runs along the back of the thigh to  connect to the knee at the shinbone. Hamstrings is a group of four muscles; Gracilis, Semimembranosus, Semitendinosus and Biceps Femoris. Respectively, the first three connect to the inside part of the knee and the fourth connects to the outside. Together, they are responsible for bending the knee and swinging your leg behind you while straight. This group of muscles help propel us forward or backward when sprinting. Many factors can contribute to an injury to the hamstrings including improper  stretching where the muscle is too tight, the muscle getting too tired or muscle imbalance due to poor conditioning and strengthening of this muscle group. These factors can lead to hamstring strains or a partial rupture which are more common. Although a complete rupture of this muscle is not common, if  it were to happen it would more than likely occur at the bottom of the pelvis and the muscle is left as a bundle along the back of the thigh.

The iliotibial band is the longest tendon in the body. It arises from the ends of the tensor fascia latae muscle and gluteus maximus muscle to connect from the outside of the hip down to the outside of the knee at the shinbone. This thick and wide tendon helps us raise our leg to the side (abduct) and rotate our leg outward at the hip joint. A common problem with the IT band causing pain at the knee is called IT band syndrome. This is seen in runners where the attachment segment of the tendon at the knee joint becomes very irritated as it rubs against the side of the shinbone during repeated bending and straightening of the knee. If the IT band is very tight and not well conditioned this area of the knee can become very irritated. Another common problem is called snapping hip. With this, the tendon has a “popping” or “snapping” sensation at the hip where an individual may think their hip is popping out of joint when in fact, the IT band is making all the noise. When you are standing up the IT band lays behind a bony prominence on the femur called the greater trochanter of your hip and when you bend your knee the band moves to the front of the greater trochanter. This popping is a result of the IT band gliding across this bony structure of the femur while walking or running or even getting up from a chair.

Lastly, the gastrocnemius muscle (calf muscle) attaches to the back of the knee and arises from the Achilles tendon at the ankle. The gastroc has two segments; the inside (medial) and the outside (lateral) segment. Each of them attach to the end of the thigh bone to help in bending the knee, walking and raising your heel off the ground when going up on your toes.

front ofa right knee bent open

Cartilage and Meniscus

These two structures serve as shock absorption for the knee. The cartilage is the most important surface in the knee for absorbing shock. It serves as a gliding surface for when the knee bends, straightens and slightly rotates. It is made of a thick, smooth tissue that acts as a protective covering over the ends of the longs bones at the joint space.

Injuries to the cartilage occur either with trauma or over long periods of time where these surfaces slowly deteriorate due to wear and tear. When the process is slow and gradual the damage is often worse. Eventually the cartilage is worn off and the surface of the two ends of bone are no longer gliding on a smooth surface with movement, but instead grinding together. This is very painful to the person when walking. It can also cause swelling and stiffness in the knee joint.

CLICK HERE to make an appointment

The meniscus in the knee is like a gasket and also serves as a shock absorber. The knee is the only place in the body that you find meniscus. And it is only found on the surface of the tibia (shinbone) that makes contact with the femur (thigh bone). The curvature of the meniscus as it extends from the tibia match the curvature of the end the femur (thigh bone). The fibers of the meniscus is made of a complex interlocking matrix to withstand twisting forces as the two ends of bone glide across the surface during movement. They help distribute the forces through the knee. The meniscus on the outside (lateral) part of the knee is wider, more curved and covers more surface area than the meniscus on the inside (medial) part of the knee.

image 1 of meniscusimage 2 of meniscus

Meniscus Tear #1

Injuries to the meniscus happen as a result of too much force loading on the joint at once during quick changes in speed, sudden rotation or a combination of squatting and twisting. The most common area of the meniscus to injure is the inside (medial) part. Unfortunately, the majority of tears in a meniscus occur along the inner edge closer to the center of the bone where there is not good blood supply. These tears cannot heal on their own. When they need to be surgically removed or partially removed the exchange for the relief of pain is uncovering more cartilage surface. The cartilage surface that no longer has meniscus to cover it breaks down faster causing arthritic changes in the joint.  Meniscus tears can happen in many different patterns and directions and need an MRI to be studied. The MRI along with symptoms the patient is feeling will help the physician determine whether the meniscus needs to have the injured segment taken out or if it can be repaired with stitches. There are different types of tears depending on the location and how they look. Treatment depends on the severity of the tear.

Risk Factors

Older adults and men are at increased risk. Factors that may increase your risk of:

• Degenerative tears:

o Occupations that involve kneeling and squatting

o Climbing stairs

o Previous knee injuries

o Obesity

• Acute tears:

o Participating in contact sports, such as soccer or rugby

o Poor techniques for jumping, landing, pivoting, and cutting

Symptoms

Symptoms may include:

• A popping sound at the time of the injury

• Pain and swelling in the knee

• Tightness in the knee

• Locking up, catching, or giving way of the knee

• Tenderness in the joint

Dr. Green consulting with patient

Diagnosis  ^

You will be asked about your symptoms and medical history. A physical exam will be done.

Your knee may need to be viewed. This can be done with:

·         X-ray

·         MRI scan

·         Arthroscopy

Treatment 

Talk with your doctor about the best treatment plan for you. Recovery time ranges depend on the severity of your injury. Treatment steps may include:

Supportive Care

The knee will need time to heal. Supportive care may include:

• Rest—Activities may need to be restricted at first. Normal activities will be gradually resumed as the injury heals.

• Ice—Ice therapy may help relieve swelling. You may be advised to use heat as you begin to return to normal activities.

• Compression—Compression bandages can provide gentle pressure to help move fluids out of the area.

• Elevation—Keeping the knee elevated can help fluids drain out or prevent fluids from building up

• A knee brace to stabilize the knee

• Crutches to keep extra weight off of the leg

Over-the-counter or prescription medication may be advised to reduce pain.

Physical Therapy

A physical therapist will assess the knee. An exercise program will be created to help recovery and to stretch and strengthen the muscles.

Surgery

Repair or removal of all or part of the damaged meniscus may by performed. This is usually done through small incisions of the skin. A camera and special tools are inserted through the incisions.

Prevention

To reduce your chances of a meniscal tears, take these steps:

• Maintain proper technique when exercising or playing sports.

• Wear appropriate footwear for your sport and playing surface.

• Strengthen both the quadriceps and the hamstrings.

• Consider wearing a knee brace for sports.

CLICK HERE to make an appointment with an orthopaedic surgeon

Patellar Dislocation

Dr. Green with patient #2

A patellar dislocation occurs when the kneecap slides out of place. The patella is the bone more commonly known the kneecap. It fits securely in a V-shaped groove in front of the knee so that the patella can move up and down when the leg is bent or straightened. 

Patellar dislocation is very common and occurs when the knee is bent. The patella is out of the groove when the knee is bent and can be vulnerable to dislocation with trauma. Straightening the knee will bring the patella back in place in the groove of the knee when a dislocation occurs. Treatment includes nonsurgical manipulation of the patella, immobilization, medications, and physical therapy. In some cases, surgery may be required to repair damage caused by the dislocation.

Causes 

Trauma or abnormal movement at the knee causes patellar dislocation. Examples include:

• A direct blow to the knee or from injury, such as a fall

• Tension that applies force from side-to-side on the patella

• Sudden twisting motions

Risk Factors

Factors that may increase your chance of patellar dislocation include:

• Shallow V-shaped groove on front of your knee.

• Knock knees—knees angled inward and touching when the legs are straight

• Flat feet —fallen arches in the feet

• Excess pronation of the feet—inward roll of the feet when walking or running

Other factors that can create instability in the patella include:

• Weak thigh muscles

• A patella that sits too high on the thigh bone

• Weakened and stretched ligaments from a previous patellar dislocations

Symptoms

Patellar dislocation may cause:

• Extreme pain and swelling at the knee

• Buckling under your own weight

• Stiffness

• Abnormal appearance of the knee

Diagnosis

Your doctor will ask about your symptoms and medical history. A physical exam will be done. This will include a thorough exam of your patella to check for tenderness and swelling. If possible, your doctor will have you walk. Your doctor may be able to make the diagnosis based on your symptoms.

Images may be taken of your knee. This can be done with:

• X-rays

• CT scan

• Computed tomography angiography (CTA) scan

• MRI scan

Treatment 

If the patella did not return to the V-shaped groove on its own, the doctor will manipulate it back into place.

The knee will be immobilized in a brace for stability and support. A brace may be needed for up to 4 weeks. Activities will be limited until the knee is stable again.

Medication

Medications will be given to help reduce swelling and reduce pain.

Physical Therapy

Physical therapy may be recommended to:

• Stretch and condition the quadriceps and hamstring muscles

• Maintain muscle strength, flexibility, and endurance

• Improve balance and range of motion

Improving leg strength may help prevent future dislocations.

Surgery

Surgery may be needed for recurrent patellar dislocation or dislocations with severe injuries to soft tissue. It may also be needed for those who don’t recover with standard medical therapy. Surgical procedures include:

• Arthroscopic repair of damaged cartilage, or to realign ligaments or tendons that stabilize the patella

• Reconstruction of medial patellofemoral ligament to help with stability and prevent recurrent dislocations

Prevention

To help reduce your chance of patellar dislocation, keep quadriceps and hamstring muscles strong with strengthening and stretching exercises.

CLICK HERE to make an appointment with an orthopaedic surgeon

Patella Fracture 

A patella fracture occurs when there is a break in the patella, better known as the kneecap. The patella is a large, movable bone at the front of the knee.

Causes 

Some common causes of this injury include:

• Sharp blow to the knee

• Excessive stress on the knee

Risk Factors 

Factors that may increase your risk of a patella fracture include:

• Increased age

• Postmenopause

• Decreased muscle mass

• Decreased bone mass— osteoporosis

• Participation in contact sports such as football and soccer

• Obesity, which places strain on muscles, bones, tendons, and ligaments

• Violence, such as car or car-pedestrian accidents

Symptoms

Patella fracture may cause:

• Sudden, excruciating pain in the kneecap

• Swelling, bruising, and tenderness

• Inability to extend the knee

• Difficulty walking

Diagnosis

You will be asked about your symptoms and medical history. A physical exam will be done. The doctor will look closely at the knee to see if there are signs of fracture. A straight leg test may be done.

Images can evaluate your knee and surrounding structures. These may include:

• X-ray

• CT scan

• MRI scan

Treatment 

Treatment options include the following:

Nonsurgical Approach

After the tests, the doctor will determined whether surgery is needed. If the patella is not badly injured, the doctor will place the knee in a cast. This cast may need to be worn for 6 weeks. After that, a knee brace and physical therapy will be needed. A cane or crutches may be needed.

Medication will be advised to reduce swelling and pain.

Surgery

If the patella is in pieces, then surgery will be needed. There are 2 kinds of surgery that are commonly used to treat this injury:

• Open reduction-internal fixation surgery —The doctor uses pins and screws to put the broken pieces back together.

• Patellectomy—Rarely, the doctor removes part of the kneecap or the entire kneecap.

After surgery, physical therapy will be needed. This can involve range-of-motion exercises and stretching. In some cases, another surgery will be needed to remove the pins and screws.

Depending on the injury, recovery can take weeks to several months.

Prevention

To help reduce your chance of a patella fracture:

• Do not put yourself at risk for trauma to the bone.

• Do weight-bearing exercises to build strong bones.

• Build strong muscles to support the knee, prevent falls, and to stay active and agile.

• Wear proper padding and safety equipment when participating in sports or activities.

CLICK HERE to make an appointment with an orthopaedic surgeon

Chronic diseases of the knee joint

Osteoarthritis

 

The cartilage on the ends of the bones serve as the main shock absorber of the knee. Healthy cartilage is smooth and allows for bones to glide across each other without disruption. In the case of osteoarthritis the joint surface is abnormal and is not working properly. Break down in cartilage can be painful and the body’s only other shock absorber are the muscles. It is important to strengthen and maintain good muscle tone in the person with OA. 

Other health tips include:

Weight Loss:  Weight creates the impact as a multiplier of body weight. Walking on level ground is 1.5 times your body weight on the joints, stairs is 3 times, squatting to tie shoe is 4 times.

Shoes:   Running shoes designed for shock absorption in heel with viscoelastic heel insert are best.

Activity Modification:  Avoid high impact activities; choose low impact cardio like bike or swim.

Rehabilitation:  Strengthen thigh, calf, hips and core muscles; stretch hamstrings and calf muscles; coordination/proprioception (balance) exercises; ice

Mechanical:  Unloader brace, lateral shoe wedge, stabilization brace for patellofemoral joint can be helpful.

Nutritional Supplements:  Glucosamine or chondroitin sulfate daily.

Over the Counter medication:  Anti-inflammatories like Ibuprofen, Naproxen sodium, Aspirin (enteric coated); Pain medications like Acetaminophen

Prescription Medication:  Anti-inflammatories; Pain medications like Tramadol

Knee Injection:  Cortisone, Viscosupplementation (Hyaluronic acid derivatives), PRP (platelet rich plasma), growth factors centrifuged from your own blood. Ice after activity then avoid vigorous activity for 2 days.  Assistive devices such as cane held in opposite hand; Acupuncture.

 

The pain of osteoarthritis typically increases with joint use and improves at rest. For reasons that aren't clear, although x-rays can find evidence of arthritis, the level of pain and stiffness experienced by people does not match the extent of injury noticed on x-rays.

Many theories exist about the causes of osteoarthritis, but we don't really know what causes the disease. Osteoarthritis is often described as "wear and tear" arthritis. However, evidence suggests that this simple explanation is not correct. For example, osteoarthritis frequently develops in many joints at the same time, often symmetrically on both sides of the body, even when there is no reason to believe that

equal amounts of wear and tear are present. Another intriguing finding is that osteoarthritis of the knee is commonly (and mysteriously) associated with osteoarthritis of the hand. These factors, as well as others, have led to the suggestion that osteoarthritis may actually be a body-wide disease of the cartilage.

CLICK HERE to make an appointment with an orthopaedic surgeon

SUPPLEMENTATION

Glucosamine

Inconsistent evidence hints that glucosamine can reduce symptoms of mild to moderate arthritis; a small amount of evidence indicates that regular use can slow down the gradual worsening of arthritis that normally occurs with time. It appears that most of the positive studies were funded by manufacturers of glucosamine products, and most of the studies performed by neutral researchers failed to find benefit.

How Does Glucosamine Work?

Glucosamine appears to stimulate cartilage cells in the joints to make proteoglycans and collagen, two proteins essential for the proper function of joints.6-10 Glucosamine may also help prevent collagen from breaking down.

Chondroitin Sulfate

Some evidence suggests that, like glucosamine, chondroitin might slow the progression of arthritis. The supplement chondroitin is often combined with glucosamine. Several studies have evaluated chondroitin used alone, as well, with some positive results, both for improving symptoms and slowing the progression of the disease. On balance, however, the evidence for chondroitin’s effectiveness for osteoroarthritis remains inconsistent.

S-adenosylmethionine (SAMe)

A substantial body of scientific evidence indicates that S-adenosylmethionine (SAMe) can relieve symptoms of arthritis.50,203 Numerous double-blind studies involving more than a thousand participants in total suggest that it is approximately as effective for this purpose as standard anti-inflammatory drugs

One of the best double-blind studies enrolled 732 patients and followed them for 4 weeks.205 Over this period, 235 of the participants received 1,200 mg of SAMe per day, while a similar number took either placebo or 750 mg daily of the standard drug naproxen. The majority of these patients had experienced moderate symptoms of osteoarthritis of either the knee or of the hip for an average of 6 years.

The results indicate that SAMe provided as much pain-relieving effect as naproxen and that both treatments were significantly better than placebo. However, differences did exist between the two treatments. Naproxen worked more quickly, producing readily apparent benefits at the 2-week follow-up, whereas the full effect of SAMe was not apparent until 4 weeks. By the end of the study, both treatments were producing the same level of benefit.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease in the general family of lupus. For reasons that are not understood, in rheumatoid arthritis the immune system goes awry and begins attacking innocent tissues, especially cartilage in the joints. Various joints become red, hot, and swollen under the onslaught. The pattern of inflammation is usually symmetrical, occurring on both sides of the body. Other symptoms include inflammation of the eyes, nodules or lumps under the skin, and a general feeling of malaise.

Rheumatoid arthritis is more common in women than in men and typically begins between the ages of 35 and 60. The diagnosis is made by matching the pattern of symptoms with certain characteristic laboratory results.

Medical treatment consists mainly of two categories of drugs: anti-inflammatory drugs in the ibuprofen family (nonsteroidal anti-inflammatory drugs, or NSAIDs) and drugs that may be able to put rheumatoid arthritis into full or partial remission, the so-called disease-modifying antirheumatic drugs (DMARDs).

Anti-inflammatory drugs relieve symptoms of rheumatoid arthritis but do not change the overall progression of the disease, whereas the DMARDs seem to affect the disease itself. A good analogy might be the various options available to "treat" a house "suffering" from a severe termite infestation. You could remove heavy furniture, tiptoe about instead of holding public dances, and put large beams under the joists. However, none of these methods would do anything to stop the gradual destruction of your house. These methods are like NSAIDs and other supportive techniques in that they treat only the symptoms.

A more definitive approach would be to hire an exterminator and kill the termites. In medical terms, this would be described as a disease-modifying treatment. Because medical treatments for chronic diseases are seldom as completely effective as this example, a closer analogy might be spraying a chemical that slows the spread of termites but does not stop them.

In rheumatoid arthritis, the drugs believed to alter the course of the disease (to slow it down or stop it) include antimalarials (hydroxychloroquine and chloroquine), sulfasalazine, TNF inhibitors (etanercept, infliximab, and adalimumab), interleukin-1 receptor antagonists, leflunomide methotrexate, gold compounds, D-penicillamine, and cytotoxic agents (azathioprine, cyclophosphamide, and cyclosporine). They are unrelated to one another but work somewhat similarly in practice.

Unfortunately, most of the drugs in this category can cause severe side effects. Because of this toxicity, for years a so-called pyramid approach was taken with people with rheumatoid arthritis. Physicians started with NSAIDs to help with the pain and inflammation, and progressed to successively stronger and more toxic medications only when the basic treatments failed. Natural treatments such as those described here might also be useful in early stages.

However, over the last few years, research has found that severe joint damage occurs very early in rheumatoid arthritis. This evidence has caused many authorities to suggest early, aggressive treatment with disease-modifying drugs to prevent joint damage. Nonetheless, this approach has not been universally adopted, and some physicians still prescribe NSAIDs for early stages of rheumatoid arthritis. The treatments described here may be reasonable alternative options.

Principal Proposed Natural Treatments

Rheumatoid arthritis is a difficult disease, and no alternative approach solves it easily. Even if you choose to use alternative methods, you should maintain regular visits to a rheumatologist to watch for serious complications. Finally, keep in mind that medical treatment may be able to slow the progression of rheumatoid arthritis. It is not likely that any of the alternative options have the same power.

Fish Oil

Fish oil is the only natural treatment for rheumatoid arthritis with significant documentation. According to the results of at least 13 double-blind, placebo-controlled studies involving a total of over 500 participants, supplementation with omega-3 fatty acids can significantly reduce the symptoms of rheumatoid arthritis.1,2 In addition, at least one small study suggests that it may help rheumatoid arthritis patients lower their dose of nonsteroidal anti-inflammatory medication (eg, ibuprofen).84

However, unlike some of the standard treatments, fish oil has not been shown to slow the progression of rheumatoid arthritis. It has been suggested that omega-3 supplementation is more effective when omega-6 intake (particularly arachidonic acid) is kept low, as occurs with a vegetarian diet.67 The benefits of fish oil may also be enhanced by simultaneous use of olive oil.74 A badly designed human study hints that a relative of fish oil, krill oil, might be helpful as well.79

For more information, including dosage and safety issues, see the full Fish Oil article.

Flaxseed oil has been offered as a more palatable substitute for fish oil, but it does not seem to work.8

Other Proposed Treatments for Rheumatoid Arthritis 

Boswellia

Boswellia serrata is a shrub-like tree that grows in the dry hills of the Indian subcontinent. It is the source of a resin called salai guggal, which has been used for thousands of years in Ayurvedic medicine, the traditional medicine of the region. It is very similar to a resin from a related tree, Boswellia carteri, which is also known as frankincense. Both substances have been used historically for arthritis.

Recent research has identified boswellic acids as the likely active ingredients in boswellia. In animal studies, boswellic acids have shown anti-inflammatory effects, but their mechanism of action seems to be quite different from that of standard anti-inflammatory medications.10-13

An issue of Phytomedicine that was devoted to boswellia briefly reviewed previously unpublished studies on the herb.14 A pair of placebo-controlled trials involving a total of 81 people with rheumatoid arthritis found significant reductions in swelling and pain over the course of 3 months. Furthermore, a comparative study of 60 participants over 6 months found the boswellia extract relieved symptoms about as well as oral gold therapy. However, keep in mind that while gold shots can induce remission in rheumatoid arthritis, we have no evidence that boswellia can do the same.

Another double-blind study found no difference between boswellia and placebo.15 The bottom line is that we need more research to know for sure whether boswellia is an effective treatment for rheumatoid arthritis.

For more information, including dosage and safety issues, see the full Boswellia article.

Devil's Claw

The herb devil's claw may be beneficial in rheumatoid arthritis. One double-blind study followed 89 people with rheumatoid arthritis for 2 months. The group given devil's claw showed a significant decrease in pain intensity and an improvement in mobility.16

Another double-blind study of 50 people with various types of arthritis showed that 10 days of treatment with devil's claw provided significant pain relief.17

For more information, including dosage and safety issues, see the full Devil's Claw article.

Other Herbs and Supplements

Glucosamine is best known as a proposed treatment for osteoarthritis. However, it might be helpful for RA as well. A double-blind, placebo-controlled study of 51 people with RA found that glucosamine at a dose of 1,500 mg daily significantly improved symptoms.77 It did not, however, alter measures of inflammation as determined through blood tests.

Some evidence, including small double-blind trials, additionally support the use of the following herbs and supplements for the treatment of rheumatoid arthritis:

Gamma-linolenic acid (GLA) found in evening primrose oil and borage oil 30-33,94

Cat’s claw ( Uncaria tomentosa)68

Rose hip powder88

• Chinese herbTripterygium wilfordii (either applied topically or taken orally)25,56,69,94

Note: Tripterygium wilfordii is believed to be unsafe for pregnant or nursing women, and may present risks in other groups as well.26,27,75

Highly preliminary evidence suggests potential benefits with the following herbs and supplements: methyl sulfonyl methane (MSM),40yucca,28 and a mixture of poplar, ash, and goldenrod.29

Vitamin E may reduce pain in rheumatoid arthritis, but it does not seem to reduce inflammation.37,54,55Some evidence suggests that adding vitamin E, or vitamin E plus other antioxidants, to standard rheumatoid arthritis therapy might improve results.39 However, an extremely large randomized trial involving over 39,000 women found that taking 600 IU of vitamin E every other day did not reduce the risk of rheumatoid arthritis.87

Individuals taking the drug methotrexate for treatment of rheumatoid arthritis may benefit by takingfolate supplements. Folate appears to reduce methotrexate side effects, including mouth sores, nausea, and liver inflammation.57-59 In addition, folate supplements may help reverse a more subtle methotrexate side-effect: a rise in blood levels of homocysteine.60,61 Elevated levels of homocysteine are thought to increase risk of heart-disease.

The following treatments are also sometimes proposed as effective for rheumatoid arthritis, but there is as yet little to no scientific evidence for or against their use: adrenal extract, beta-carotene, betaine hydrochloride, boron, burdock, cayenne, chamomile, copper, feverfew, folate, ginger, L-histidine, horsetail,magnesium, manganese, molybdenum, pantothenic acid, D-phenylalanine, perilla frutescens,pregnenolone, proteolytic enzymes, sea cucumber, and vitamin C.

Current evidence regarding green lipped mussel for rheumatoid arthritis is more negative than positive.62-66

One study failed to find vitamin B6 at a dose of 50 mg daily helpful for rheumatoid arthritis, despite a general B6 deficiency seen in people with this condition.76

Zinc supplements have been evaluated as a treatment for rheumatoid arthritis, but overall the study results have not been encouraging.34,35,49-53 Other treatments that have as yet generally failed to prove effective in small double-blind trials include selenium, collagen,46,47-50probiotics,72white willow,73 and an Ayurvedic herbal mixture containing extracts of ashwagandha, boswellia, ginger, and turmeric.45 Two studies commonly cited as evidence that turmeric alone is useful for rheumatoid arthritis actually fail to provide any meaningful supporting evidence.20,21

A 6-month, double-blind, placebo-controlled study of 168 people with rheumatoid arthritis failed to find that elk velvet antler enhanced the effectiveness of conventional treatment for rheumatoid arthritis.83

Other Alternative Therapies

Adopting a vegan (pure vegetarian) diet might help mild rheumatoid arthritis, although the supporting evidence is weak.41,42

Identifying and avoiding food allergens has also been tried,43 but one controlled trial found no clear evidence of benefit with a low saturated fat, hypoallergenic diet.44

Balneotherapy (hot baths),78relaxation therapy,80-82 and magnet therapy70 have shown a bit of promise for rheumatoid arthritis.

Two separate groups of researchers conducting detailed reviews of 8 randomized controlled trials found some beneficial effects of acupuncture for rheumatoid arthritis, but were unconvinced that it was more beneficial than sham acupuncture or other standard treatments.85,86 Another review of 11 randomized trials did not find that mediation, progressive muscle relaxation, static magnetic therapy, acupuncture or tai chi relieved pain in patients with rheumatoid arthritis. The 11 trials included a total of 607 patients.95

Homeopathy has also been evaluated for rheumatoid arthritis with no consistent evidence of beneficial effect.89-93

Herbs and Supplements to Use Only With Caution  

Various herbs and supplements may interact adversely with drugs used to treat rheumatoid arthritis. For more information on this potential risk, see the individual drug article in the Drug Interactions section of this database.

Gout

Gout is an inflammatory condition that is caused by the deposit of uric acid crystals in joints (most famously the big toe), as well as other tissues. Typically, attacks of fierce pain, redness, swelling, and heat punctuate pain-free intervals.

Medical treatment consists of anti-inflammatory drugs for acute attacks (ie. colchicine) and of uric acid-lowering drugs for prevention (ie. allopurinol).

Alternative Treatments for Gout

The following herbs and supplements are widely recommended for gout, but as yet they have no reliable scientific support:

Vitamin C

In a double-blind, placebo-controlled study of 184 people without gout, use of vitamin C at a daily dose of 500 mg significantly reduced uric acid levels.7 This suggests, but falls far short of proving, that vitamin C might be helpful for preventing or treating gout.

For more information, including dosage and safety issues, see the full Vitamin C article.

Folate

Folate has been recommended as a preventive treatment for gout for at least 20 years. Some clinicians report that it can be highly effective. However, what little scientific evidence we have on the method is contradictory.1,2,3 It has been suggested that a contaminant found in folate, pterin-6-aldehyde, may actually be responsible for the positive effects observed by some clinicians.

For more information, including dosage and safety issues, see the full Folate article.

Devil's Claw

The herb devil's claw is sometimes recommended as a pain-relieving treatment for gout based on evidence for its effectiveness in various forms of arthritis.4 However, it has not been tested in gout.

For more information, including dosage and safety issues, see the full Devil's Claw article.

Cherries

Cherries are also claimed to be helpful for gout, based primarily on a single "scientific" study performed in the 1950s.8 In fact, however, this study was far too poorly designed to prove anything at all, because it did not utilize a placebo group. (For information on why a placebo group is essential, see Why Does This Database Rely on Double-Blind Studies?) A much more recent study did find some evidence that cherry consumption might lower levels of urate in the blood.7 Although high levels of urate are associated with gout, we can not conclude that cherries can directly benefit gout based on this trial. Another larger study did assess direct benefits of cherry on gout when the study assessed the risk of recurrent gout attacks in 633 people using cherries or cherry extract two days prior to a gout attack. Participants taking cherries or cherry extract had 35% lower risk of gout attacks than when they did not use cherries or extract. Further, the addition of cherry consumption with allopurinol treatment reduced the risk of gout attacks by 75% when compared to using only one of either treatment.8. Both trials did have had some design issues that may reduce reliability.

Traditional Chinese Herbal Medicine

Traditional Chinese herbal medicine (TCHM) has a long historical tradition, although it is not quite as ancient as popularly believed. In China today, TCHM is used alongside conventional pharmaceutical treatment. Considerable attempts have been made to subject TCHM to scientific evaluation however, most of the published Chinese studies on the subject fall far short of current scientific standard, making it impossible to determine true benefits. Chinese herbal medicine is also a unique mix of herbs with potency and makeup that can vary greatly between prescriptions.

A review of 17 randomized trials involving TCHM appears to show promise as a treatment for acute gout attacks. In these trials, TCHM was compared to traditional Western medications (colchicine, allopurinol, colchicine plus allopurinol, diclofenac, or meloxicam) in 1,402 people with acute gout symptoms. TCHM had similar improvements in clinical blood markers of gout as traditional medication but TCHM was associated with fewer side effects. However, all trials in this review had several biases, which affect the reliability of the results.9

Other Supplements

On the basis of interesting reasoning but no concrete evidence of effectiveness, fish oil, olive leaf, vitamin E, selenium, bromelain, vitamin A, and aspartic acid have also been recommended for both prevention and treatment of gout.5

Folk Remedies

Celery juice is a traditional folk remedy for gout that is said to be widely used in Australia.


 

 

 

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