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

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

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 for knee replacement, complication risk in Type 2 diabetes patients is another great concern.

Medications, 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 changes in diet and lifestyle. Changing 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 are 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 on 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, with 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, with 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 for 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 the diabetic synovial membrane but also by the systemic low-grade inflammation state related to obesity and insulin-resistant state.
    • In other words, Insulin resistance is when 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."
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.”

The negative impact of diabetes on post-knee replacement recovery

An April 2024 study (3) led by the Krembil Research Institute, University Health Network, Toronto writes that: “Findings support that diabetes has a negative impact on improvements in physical health after total joint replacement. Considering the growing prevalence of osteoarthritis and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing total joint replacement.”

Type 2 diabetes prevents bone repair which damages your cartilage

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

In the medical journal Bone Research(4) 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, 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 for knee replacement are coming into play.

Type 2 diabetes and knee osteoarthritis increase fall risk

A December 2022 paper in the journal Medicine (5) 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 measured by standard Knee Injury and Osteoarthritis Outcome Score (KOOS), who also had a 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 published in February 2018 in the Journal of Magnetic Resonance Imaging (6) found that not only did Diabetes type 2 accelerate knee osteoarthritis, but the more unmanaged or severe 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.(7Doctors 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. (8)

In November 2019, doctors at the University of Texas wrote in the Journal of diabetes research (9) 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 treat 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.

Diabetes a risk for implant loosening

An April 2023 study in the journal BioMed Central Musculoskeletal Disorders (10) found that “the incidence of diabetes mellitus is significantly greater in patients undergoing revision arthroplasty for aseptic loosening.”

Prolotherapy injections and uncontrolled type 2 diabetes

A March 2024 study in the journal Frontiers in Endocrinology (11) investigated glucose metabolism and its role in maintaining cartilage homeostasis. Here is a summary points:

  • Glucose plays an essential role in the maintenance of chondrocyte metabolism (the production of collagen for cartilage repair), and adequate glucose supply is required to maintain the major anaerobic metabolism of articular chondrocytes. (Rebuilding cartilage). In addition, glucose is also a key precursor for the synthesis of extracellular matrix macromolecules by these cells (The extracellular matrix is the “mortar” that holds cells in place that repair holes. Please see my article: What is the extracellular matrix?

What the researchers speculate is that for the body to repair osteoarthritis damage, the area of repair may need more glucose to produce chondrocytes (cartilage cells) but this process is limited due to the avascular nature of cartilage tissue (or the lack of blood supply). Next, through developing past research, the researchers speculate that limited glucose supply carries the risk of impairing cellular function and may lead to an imbalance in matrix synthesis and degradation, resulting in osteoarthritis.

  • They note “sufficient glucose supply to chondrocytes promotes cartilage repair by interrupting the harmful inflammatory cycle and inducing the synthesis of Hyaluronic acid, suggesting that intra-articular injection of glucose is beneficial to the early treatment of osteoarthritis, and its combination with other therapies is expected to improve the therapeutic effect by regulating chondrocytes metabolism and inducing anti-inflammatory processes.”

Here is the connection to diabetes mellitus and type 2 diabetes mellitus are significantly associated with osteoarthritis, and diabetic patients have a higher risk of osteoarthritis suggesting that hyperglycemia may induce or aggravate osteoarthritis (too much sugar).  . . Prolotherapy is a safe nonsurgical regenerative injection technique that stimulates the production of growth factors and cytokines and promotes the growth of normal cells and tissue by injecting small amounts of a stimulating solution (including hypertonic dextrose, morrhuate sodium, dextrose/phenol/glycerin solution, or platelet-rich plasma) into painful and degenerative joints . . .While individuals may experience short-term relief, questions remain about the long-term durability of the treatment. This uncertainty can make it challenging to assess the suitability of treatment for sustained management of knee osteoarthritis. Additionally, the dextrose concentration/volume, interval, and duration of treatment, as well as injection site and technique may differ. The absence of standardized treatment protocols for dextrose prolotherapy contributes to variability in how the procedure is performed. Therefore, despite the promising results, there is still a need for larger clinical trials with a standardized treatment.”

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 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 knee osteoarthritis (12).

  • 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 led 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%). (13)

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 are 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 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 lose weight for 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 lose some weight.

For a person with a 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.


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