A Patient’s Story
(As told by Paul Hattam, Principal Physiotherapist & Director at "The Physios" in Sheffield https://www.thephysios.com/)
M. has always been fit and active - but her love of running and hiking has had to be replaced in recent years by cycling in order to accommodate the symptoms caused by ‘wear and tear’ in her knees. Nevertheless, M. takes her cycling seriously, especially when it comes to many of the hill climbs in her native Sheffield and maintains a friendly rivalry with her husband!
M. attended our physiotherapy clinic because of the worsening knee pain that even the cycling had begun to provoke. A diagnosis of osteoarthritis was made and a management strategy was planned. Initially she was able to manage the pain with some physiotherapy treatment (see manual therapy) and conditioning exercises (see exercise), but her pain and reduced function started to become increasingly intrusive to the point where walking short distances and crouching down to play with her grandchildren was really painful. Periods of inactivity, such as long car journeys, were painful and her sleep was affected due to the pain when turning over in bed. Inevitably, M. had to stop cycling too.
Feeling a little despondent about the situation, M. went to see her GP who arranged for her to have an X-ray and prescribed some non-steroidal anti-inflammatory drugs (see NSAID’s) which didn’t help that much. The X-ray confirmed severe osteoarthritis affecting the knee joint and patella (knee cap). Her deteriorating situation forced her to see an orthopaedic surgeon who offered a total knee replacement (see TKA).
When we re-assessed M.'s knee it was severely swollen and she also had a very large Baker’s cyst at the back of the knee. The knee was showing signs of more advanced arthritic changes with simple bending and straightening movements were painful and stiff with crepitus evident. Finding a good solution without surgery would be challenging. For M. though it was vital that she could return to cycling and she didn’t want to consider surgery if at all possible.
So we decided to discuss the option of hyaluronic acid injections (see hyaluronic injections) with M. as this provides an excellent alternative to surgical intervention in many cases. M. had previously been given a steroid injection (see steroid injection) by her GP but this had only provided short term pain relief so she was keen to consider other options. Unlike steroids, where repeated doses could cause harm to the joint, injecting hyaluronic acid helps to restore normal conditions within the joint, is a tried and tested treatment for patients with this condition and carries negligible risks. This rather appealed to M. and she agreed to proceed with the injection. The injection was done under ultrasound imaging which enables the clinician to guide the injection to exactly the right place.
M. explains, "The procedure takes a couple of minutes and is really quite tolerable. The effect of the injection was gradually noticeable over a few weeks - not dramatic at all but I began to realise I could do things that had previously been painful”.
After a few months of physio and exercise therapy the symptoms started to worsen again and M. returned to the clinic. The joint was swollen and painful and given the partial and temporary improvement from the previous separate injections, we decided to combine the steroid and hyaluronic acid for a final injection treatment (see combined HA and steroid injections).
Of course a stand-alone injection does not demonstrate best practice as studies have shown that the outcomes of combining injection therapy with a personalised, tailored rehabilitation programme are much superior .
Firstly movement at the knee needed to be recovered - there are a lot of small but essential ‘accessory’ movements that allow the bending (flexion) and straightening (extension) to occur and physiotherapy techniques helped to restore the global movement of her knee and kneecap (see manual therapy) Importantly, she needed to be able to bend her knee enough to reach the top of the pedalling motion comfortably.
M. was then given an exercise programme that was individualised and goal based. For M. it was important to increase both the amount of time she could cycle and the resistance; and to return to cycling the hills of Sheffield. She started with low resistance cycling which progressed to longer sessions against more resistance. Strength training was another important component in the recovery. The thigh muscles (quadriceps) are key in delivering the force required when cycling and building endurance is fundamental. Proprioception retraining was the final component of M.’s recovery. It is possibly helpful to think of this as preparing for all the small, unplanned movements that we unconsciously negotiate every day. For example, if you are standing on a bus and its turns a sharp corner or you step on an uneven surface. For M. we started these exercises simply but little and often. We then progressed these exercises to really test M.’s balance and stability (see Exercise).
From the beginning M.’s primary goal was to return to cycling, not just for cycling sake but to return to the camaraderie of her cycling club which was as important to her as the physical benefits of the exercise. However as keen as she was, it was important that resumption of longer rides into the Peak District was gradual, particularly following an injection because the pain can be dramatically reduced which gives the impression that the problem has gone and people do too much, too soon. This can result in pain or swelling in the knee or development of a secondary injury because your body is deconditioned.
M.'s recovery was complete and she was discharged without the thought of a knee replacement lurking in her mind. A few weeks later she emailed a progress report:
The good news is that my knee is much improved since the injection three weeks ago. The pain is much reduced, I can move faster and better and even managed to run quite a long way for a bus! Hope this continues as life is much better. Thank you so much for your combined help and hope to see you in a year's time for another injection to keep me away from the surgeon's knife.....
 FOSTER, Z. J. et al. (2015) ‘Corticosteroid Injections for Common Musculoskeletal Conditions’, American Family Physician, 92(8), pp. 694–699. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=110135924&site=ehost-live (Accessed: 27 April 2019).
 Mittal, N., Kumbhare, D. and Bhandari, M. (2018) ‘Are Corticosteroid Injections Safe to Inject into Knees With Osteoarthritis? What Are the Long-term Effects?’, American Journal of Physical Medicine & Rehabilitation, 97(6), pp. 461–464. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=129676231&site=ehost-live (Accessed: 27 April 2019).
 Calvet, J. et al. (2018) ‘Clinical and ultrasonographic features associated to response to intraarticular corticosteroid injection. A one year follow up prospective cohort study in knee osteoarthritis patient with joint effusion’, Plos One, 13(1), p. e0191342. doi: 10.1371/journal.pone.0191342.
 Nattapol Tammachote et al. (2016) ‘Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial’, Journal of Bone & Joint Surgery, American Volume, 98(11), pp. 885–892. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=115868908&site=ehost-live (Accessed: 27 April 2019).
 Ertürk, C. et al. (2016) ‘Will a single periarticular lidocaine-corticosteroid injection improve the clinical efficacy of intraarticular hyaluronic acid treatment of symptomatic knee osteoarthritis?’, Knee Surgery, Sports Traumatology, Arthroscopy, 24(11), pp. 3653–3660. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=119110914&site=ehost-live (Accessed: 27 April 2019).
Saccomanno, M. et al. (2016) ‘Efficacy of intra-articular hyaluronic acid injections and exercise-based rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis’, Knee Surgery, Sports Traumatology, Arthroscopy, 24(5), pp. 1686–1694.
 Pollard, H., Ward, G., Hoskins, W., & Hardy, K. (2008). The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. The Journal of the Canadian Chiropractic Association, 52(4), 229–242.
Manual therapy or hands-on treatment is an important skill for physiotherapists - in fact The Chartered Society of Physiotherapists owes its heritage to massage therapy. There are many different treatments that a physiotherapist can apply with their hands including; massage, joint mobilisation, manipulation and facilitating someones natural movement. Manual therapy can be beneficial for reducing the pain caused by an injury and to provide confidence for a person to move or exercise effectively .
Exercise. Love them or hate them, we are all aware that exercise is vital following a musculoskeletal injury. Exercises are important to improve and retain the range of movement, support the injured joint or structure and restore the weakness produced by being unable to use the muscles effectively during injury. For any knee injury or arthritis, I am an advocate of an exercise bike or even a small pedal exerciser. Initially this is little and often – perhaps for 5 mins a few times per day. In the early stage it is all about movement not resistance. It doesn’t even matter if you cannot manage to turn the pedals all the way round – just work the pedals back and forth until it is comfortable to complete the full cycle. Cycling helps to move the knee without loading/standing on it and maintains the condition of your muscles.
NSAIDs (Non-steroidal anti-inflammatory drugs) such as Ibuprofen and Naproxen are used for a range of conditions including knee arthritis. NSAIDs exert their action by affecting a particular group of enzymes in the body called cyclooxygenase (COX). Whilst these COX enzymes are responsible for inflammation, they also have a role in protecting the stomach and intestinal system. The use of NSAIDs (particularly if prolonged) can have detrimental effects on the stomach/intestines producing symptoms like indigestion or heartburn. However they are useful drugs to reduce inflammation in the short term.
TKA (total knee arthroplasty) - is a routine operation that involves replacing a damaged, worn or diseased knee with an artificial joint. Adults of any age can be considered for a knee replacement, although most are carried out on people between the ages of 60 and 80. More people are now receiving this operation at a younger age. Knee replacement surgery is usually necessary when the knee joint is worn or damaged to the extent that your mobility is reduced and you experience pain even while resting. The most common reason for knee replacement surgery is osteoarthritis.
Steroid injections have been widely used in the treatment of inflammatory conditions affecting the joints including osteo and rheumatoid arthritis . The inflammatory process of arthritis causes pain, swelling and loss of function and is dampened down by the powerful anti-inflammatory effect of the steroids. There is good evidence that shows its benefit in the short term (somewhere between 3 weeks and 3 months) but this sometimes does not provide a satisfactory treatment option as repeated injections of steroid have been shown to be harmful to the joint. Some people do report longer term benefit but this is by no means a given.
Hyaluronic acid is a natural constituent found within the joint structure and helps to provide viscosity and elasticity to the joint fluid - important features of a healthy joint. Arthritis adversely affects the normal conditions within the joint and injecting HA helps to restore this, thereby reducing the symptoms associated with the condition. There is increasing evidence to show that its effect is longer lasting than steroid and that side effects are minimal making this an attractive choice for both clinicians and patients 
Combined hyaluronic and steroid injections can be efficacious in cases where the short term benefits of steroid and the longer lasting effects of the hyaluronic acid are needed . This might be an option where the joint is very irritable and inflamed as the steroid is invariably the best way of treating this and the addition of HA helps to ensure that the longer term health of the knee is addressed too.