Your knee pain is not just ‘wear and tear’ – expert orthopedic surgeon Fabian Poletti on what most people miss

WHEN patients are told they have knee osteoarthritis, the explanation often sounds mechanical: ‘wear and tear.’ It is simple. It is reassuring.

And it is incomplete. The ‘wear and tear’ explanation suggests that cartilage loss in the knee is the problem.

However, osteoarthritis does not affect cartilage alone. It involves the entire joint as an organ. Cartilage, bone, ligaments, surrounding muscles – and in the knee, the menisci – all participate in the disease process.

The bone beneath the cartilage can become harder and change shape over time with ongoing stress. The joint lining can become inflamed.

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: Living with pain? UK-trained senior orthopaedic surgeon Fabian Poletti reveals the best way to end the agony Ligaments may slowly lose their tightness, and muscles can weaken, which affects how the joint moves and stays stable.

Meanwhile, the cartilage – under both pressure and inflammation – gradually becomes less able to cushion and protect the joint. Importantly, cartilage itself has no nerve endings. Pain often arises from subchondral bone, synovium and surrounding soft tissues reacting to structural and biochemical changes.

This is why knee osteoarthritis cannot be reduced to simple cartilage loss. It is also why claims focused solely on ‘cartilage regeneration’ are incomplete. Even if cartilage thickness could be partially influenced, restoring joint health requires addressing the entire joint environment – alignment, bone quality, muscle strength and inflammation.

Treating one tissue while ignoring the rest of the joint rarely changes the long-term trajectory. Understanding osteoarthritis as a disorder of the joint as part of the body’s wider system changes the conversation entirely. It shifts the focus from a single structure to a biological system.

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: Cooking dinner at home once a week could help stave off dementia risk, new study reveals And that system does not exist in isolation. The knee reflects the metabolic environment of the body. In many individuals, osteoarthritis represents the end stage of a prolonged interaction between mechanical load and low-grade chronic inflammation.

Adipose tissue – particularly visceral fat – is biologically active. It releases inflammatory mediators known as adipokines, which circulate systemically and influence cartilage metabolism, synovial activity and pain sensitivity. Over time, a pro-inflammatory internal environment reduces the joint’s capacity to tolerate normal stress.

This does not mean nutrition ‘cures’ osteoarthritis. It does mean that the environment the joint operates in plays an important role. One of the most consistently supported dietary patterns for reducing systemic inflammation is the Mediterranean diet: whole foods, vegetables, legumes, nuts, olive oil, adequate protein intake, and limited ultra-processed carbohydrates.

This diet can reduce inflammation and support blood sugar regulation. Blood sugar regulation is extremely relevant to joint biology. Chronic insulin resistance is associated with inflammation.

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: Malaga hospital at breaking point: Patients are waiting 65 hours and being treated in corridors, staff claim Persistently high glucose levels contribute to oxidative stress, which may affect cartilage homeostasis and pain sensitivity. Protein intake is another overlooked factor. Muscle is protective.

Quadriceps weakness increases joint load and destabilises knee mechanics. Adequate high-quality protein intake supports muscle maintenance, particularly after the age of 50, when sarcopenia becomes a genuine risk factor for poorer outcomes – both in the management of osteoarthritis and after surgery. Sleep is equally critical, yet frequently underestimated.

Restorative sleep is not passive rest. During deep sleep phases, inflammation is regulated, tissue repair processes are activated and the body can manage pain. Chronic sleep deprivation increases circulating inflammatory markers and amplifies pain perception – sometimes out of proportion to imaging findings.

Over time, this contributes to central sensitisation, where the nervous system becomes more reactive to mechanical input. Addressing sleep quality – through consistent sleep schedules, reduction of late-night screen time and treatment of conditions such as sleep apnoea – is an important part of caring for your joints. Beyond dietary patterns and sleep regulation, certain nutritional components have been studied for their anti-inflammatory properties.

Omega-3 fatty acids, particularly EPA and DHA, influence the balance of inflammatory mediators. In patients with diets disproportionately high in processed seed oils and low in oily fish, an increased intake of Omega-3s may help control inflammation. Vitamin D also plays a role in immune regulation, bone metabolism and muscle function.

Deficiency in Vitamin D remains common despite abundant sunlight in Southern Europe. Correcting this deficiency does not reverse osteoarthritis, but it does support musculoskeletal resilience. Compounds such as curcumin and Boswellia extracts have demonstrated anti-inflammatory effects in laboratory and selected clinical studies.

These supplements can also help control inflammation.

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: EXPLAINER: How Spain’s euthanasia law works after paraplegic gang-rape victim Noelia, 25, chooses to end her life In some people, treatments made from their own blood can be injected into a joint to help calm inflammation, especially in the earlier stages of osteoarthritis. These treatments aren’t meant to rebuild badly damaged cartilage or fix structural issues, but rather to improve joint health in carefully selected cases. These approaches fit into a clear treatment pathway.

When joint damage is still mild, treatments that support the body’s natural processes can help ease symptoms and maintain function.

However, as the problem worsens – when the joint becomes misaligned, cartilage wears away, or bones begin to rub against each other – more direct solutions are needed. In these cases, surgery to realign the joint or replace it altogether becomes the most effective option. The objective is not to avoid surgery at all costs.

It is to intervene intelligently – addressing metabolic drivers early, preserving muscle strength, optimising sleep and systemic health, and applying surgical reconstruction at the appropriate stage of disease. Osteoarthritis isn’t only about damage in a single joint. It’s part of a wider condition in the body, even though the symptoms appear in one place.

Ageing is inevitable and joint use is unavoidable.

However, the factors which cause osteoarthritis can be influenced and improved. The knee may be where pain is felt. But its trajectory of osteoarthritis is shaped long before symptoms appear.

Dr Fabian Poletti is a UK fellowship-trained Consultant Orthopaedic and Trauma Surgeon, FRCS (Eng), FEBOT, MSc (Imperial), DIC. He held senior clinical posts at the UK’s NHS and is listed on the GMC Specialist Register. He later served as Chief Physician in Denmark and has extensive experience across both the Spanish public and private healthcare systems.

He currently practises in Marbella, Estepona and Gibraltar. Further information is available at www.drpoletti.com/en, with consultations in Marbella, Estepona and Gibraltar.