Nonoperative Options for Management of Articular Cartilage Disease

Key points

Oral medications: acetaminophen, nonsteroidal anti-inflammatory drugs, opioids

When patients are no longer experiencing sufficient symptom relief from nonpharmacologic methods, either oral or topical analgesics are typically initiated as an adjunctive therapy. A logical first choice is acetaminophen due to greater safety and a lower side-effect profile than nonsteroidal anti-inflammatory drugs (NSAIDs). As such, it is consistently recommended as a first-line pharmacologic treatment option.¹ There is low-level evidence on the effectiveness of acetaminophen for OA pain in

Topicals: nonsteroidal anti-inflammatory drugs, lidocaine, capsaicin

Another option for patients who want to try pharmacologic treatment but wish to minimize systemic effects is topical therapy. Topical treatments deliver local analgesic effects with minimal systemic absorption. Options include topical NSAIDs, such as diclofenac, lidocaine, and capsaicin. A 2016 Cochrane review evaluated 33 RCTs on topical NSAIDs for chronic musculoskeletal pain due to OA.²⁰ In studies ranging 6 to 12 weeks, 60% of patients had a significant decrease in pain compared with

Supplements: glucosamine, chondroitin, others

Many patients with articular cartilage disease wishing to avoid traditional pharmacologic treatments or their associated side effects turn to over-the-counter supplements. Two of the most commonly used supplements are glucosamine and chondroitin sulfate, either alone or in combination. The estimated $810 million US consumer market for the 2 supplements in 2005 demonstrates the extent of use.²² The rationale behind glucosamine use is related to its presence in human articular cartilage.

Steroid injections

Although it has been described as a degenerative process, current understanding of the pathophysiology of OA involves a cascade of inflammatory mediators in the joint. Corticosteroid injections are performed with the intention of reducing pain and improving function by producing a powerful local anti-inflammatory effect.³¹ The effects of corticosteroid injections are most notable in the short term, resulting in significant decreases in pain.² This makes steroid injections a reasonable option

Viscosupplementation

Viscosupplementation is a technique that involves the injection of exogenous high molecular weight hyaluronic acid molecules to combat the effect of the decreased viscoelasticity of synovial fluid seen in OA.³⁷ It is typically the second-line choice for injection therapy if the effectiveness of corticosteroids is limited. It is also used without prior corticosteroid injections for younger, physically active patients. Viscosupplementation is a good alternative in situations in which

Prolotherapy (and biologics)

Prolotherapy is an injection technique that uses nonbiologic irritant solutions, most commonly dextrose.⁴³ The mechanism of action is multifactorial and not well understood, but proposed mechanisms include stimulation of a local healing process in tissue with chronic damage, decreasing joint instability by increasing the strength of tendons and ligaments, and stimulating cell proliferation.⁴⁴ Animal studies have suggested cartilage-specific anabolic growth. A recent small study used

Summary

Nonoperative options for articular cartilage injury are omnipresent but have not shown to be curative. Recommendations for low-impact exercise and weight loss provide benefit and are a foundation for the treatment of OA. Many options are available to manage the pain associated with OA and their use should be based on an individualized consideration of the risks and benefits afforded the patient. Future studies to individualize treatment options based on patient phenotype and genotype may hold