More than a year ago, the shooting pain started in one knee. Then the other. At its apex, the pain prevented him from playing with his two young kids. Climbing stairs was excruciating. He didn't work out for about six months while he was figuring it all out, and that was bad for his mental health.
A sports medicine specialist told him knee osteoarthritis was degenerative and would only get worse, "which is a hard thing to hear, especially because I'm only 35 years old and my profession involves me being on my feet and using my legs. andhellip; I've always been fit, not overweight, always active and doing the right things. So for a few months I was crabby and upset about it," he said.
Nokes asked his orthopedic surgeon to give him total knee replacement surgery. But replacements are not generally recommended for people Nokes' age. For now, he's learning how to manage the pain so he can keep teaching tennis in Sunriver, Ore. and he's delaying knee surgery as long as possible.
Osteoarthritis is a common malady in middle-aged and older people, but it can also be a young person's problem, and that demographic is growing.
Americans are expected to be diagnosed with knee osteoarthritis at much younger ages this decade than in previous decades, according to a recent study from the Orthopedics and Arthritis Center for Outcomes Research at the Brigham and Women's Hospital in Boston. The average age of patients diagnosed with knee osteoarthritis is projected to fall from age 72 in the 1990s to 56 in the 2010s - a 16-year difference. The study also says about 5 percent of all Americans ages 45 to 54 would be diagnosed with knee osteoarthritis over the next decade, compared with only 1.5 percent during the 1990s.
This younger diagnosis might reflect a higher participation in sports within a segment of the population, said Dr. Sharon Kolasinski, a professor of medicine at the Cooper Medical School at Rowan University and the head of the rheumatology division at Cooper University Hospital in New Jersey. These active athletes demand more from their joints and are more likely to injure their knees than sedentary people. Certain knee injuries predispose people to accelerated osteoarthritis, she said.
"The flip side is that the remarkable increase in obesity of another segment of the U.S. population is clearly leading to an increase in knee osteoarthritis due to the biomechanical stress of obesity as well as possible metabolic effects of increased body fat," she said.
Dr. Kathryn Schabel, a knee and hip expert at Oregon Health and Science University in Portland, said knee osteoarthritis can stem from poor genetic luck; some people are just born with cartilage that just wasn't made to last.
But most of the cases of younger patients - people Nokes' age - result from a more discernible activity-related cause, Schabel said. Injuries to the knee ligaments, meniscus (cartilaginous tissue), articular cartilage or bones increase the risk of accelerated osteoarthritis. Even "subclinical" fractures that never required medical care can increase the risk.
Knee osteoarthritis also results from having lower-extremity deformities such as knocked knees or bowed legs, Schabel said. Those alignment deformities make knees work abnormally, wearing on some parts excessively.
Any extra body weight would compound any of these factors by adding extra force to the joints in any movement, she said.
Some sports are risky
In general, activity is good for the joints, in part because it keeps a person's weight down. In addition, the articular cartilage in the joint gets its nutrition from synovial fluid that surrounds the cartilage when the joint is in motion. Joints get stiff and painful from immobilization.
But some higher-impact sports, such as basketball and downhill skiing, are associated with a higher risk of developing osteoarthritis.
A study led by Jeffrey Driban, a research associate at Tufts Medical Center, pointed to soccer, long-distance running, weight lifting and wrestling as other activities that may increase the risk.
Last year, Driban's research team reviewed 16 studies, looking for an association between sports participation and knee osteoarthritis. Among the 3,192 men in the studies, 8.4 percent of former sports participants had knee osteoarthritis compared with 9.1 percent of people who did not participate in sports. So, overall, the results reflected no higher risk - or even a slightly lower risk - for former athletes.
But, risk depended on the specific sport played and the level of competition. Both elite and non-elite soccer players, as well as elite long-distance runners, weight lifters and wrestlers were found to be at an increased risk.
"The most reassuring aspect of the data is that most sports probably do not increase the risk of developing knee osteoarthritis, especially when competing at a recreational level," Driban said.
Sports such as swimming or cycling might be less wearing on the knees, he suggested.
There's a menu of nonsurgical treatments that can relieve a person's pain and keep them active. They are more like Band-Aids, though - there's no absolute cure.
Schabel, from OHSU, said she first asks overweight patients to lose weight to reduce the load on the knees.
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Tim Bollom, a sports medicine specialist at The Center: Orthopedic and Neurosurgical Care and Research in Bend, Ore., sees a lot of athletes for knee osteoarthritis in their 30s and 40s. He suggests modifying one's exercise routines.
"I encourage lower-impact sports, lower-resistance training," Bollom said. "Biking, swimming, walking instead of running."
Nokes, who is Bollom's patient, has diversified his exercise routines. He avoids hard workouts back to back. If his knees feel particularly stiff one morning, he takes the day off. He uses ibuprofen and ice to reduce the inflammation and swelling.
Experts say physical therapy helps some patients.
And, for people with deformities, braces on the legs or orthotic inserts in the shoes may counteract alignment issues and change the points of pressure in the knees.
More invasive than supplements or pain relievers, there's an array of knee injections to consider.
The most common is corticosteroid, known as cortisone, a potent anti-inflammatory. Injections can be mildly painful but are very safe and have few complications. The main risk with any injection is the potential to introduce an infection.
Another treatment, called a viscosupplementation, is an injection of what's called hyaluronic acid into the knee. The hyaluronic acid is a natural component of our knee's cartilage. Most injections are derived from rooster combs for the purpose of lubricating the knee.
Nokes gets hyaluronic lubricant injections to get through his busy spring and summer tennis season. That worked for him last year and he's going to try again this season.
Injections have the greatest effect when the damage is less severe. Their efficacy diminishes over time. The body gets immune, or desensitized, to the drug because receptors that the drugs bind to get reduced or depleted.
Glucosamine supplements have some evidence backing them. Glucosamine may decrease the loss of cartilage over time and has been shown to improve symptoms of moderate knee arthritis. It's safe. But, it needs to be taken regularly and can cost about $1 a day. Also, it's not Food and Drug Administration-regulated, so pill contents can vary.
Anti-inflammatories are helpful for the short term, but long-term use can damage the liver and kidneys. Anti-inflammatory medications are associated with stomach ulcers and gastrointestinal bleeding. Patients with liver, kidney or gastrointestinal problems, on blood thinners or with diabetes should not use them.
Acetaminophen is fairly safe analgesic, but its side effect is liver toxicity, so it shouldn't be taken too much or over the long term. Opiod pain medications are not recommended. (Vicodin, Oxycodone, for example.)