We live in a world of over activity (weekend warrior athletes and ultra marathoner) or under activity (overweight, unfit, desk workers). These two extremes of activity may predispose early joint changes. It is common knowledge that most Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) surgeries are reserved for those > 65 years old because the hardware has a life of around 10-20 years. What about the active people that may have a physical alignment issue such as leg length discrepancy, scoliosis, genu varum/vaglus (bowed knees or knock knees) AND decide they are going to go ahead and train their bodies until they break down? This list of contributing factors is JUST that. They do not guarantee you will develop arthritis or joint surface changes. If trained correctly and progressively most people’s bodies will adapt to the load. The fact is, many people do not train correctly or patiently. This leads to overuse injuries. If those injuries are not treated with rest, rehabilitation, and progressive return to activity early arthritis may develop.
In reality most people we are talking about do not have arthritis, rather “chondral changes” to the joint surface. We need to make it clear that ARTHRITIS AND CHONDRAL CHANGES ARE TWO SEPARATE PROBLEMS. Arthritis is an autoimmune disease; thus if the immune system attacked and destroyed parts of the patient’s cartilage previously, it will probably attack and destroy newly implanted chondrocytes as well. An understanding of what is occurring in the joint and the types of tissues involved is imperative to determining the course of action that aids the return to an active life.
- Hyaline – smooth, white cartilage on the end of bones that also contributes to shock absorption with activities like jumping, running, and pivoting. It is important to know that this type of cartilage does not have a blood supply so it can not be healed.
- Chondrocytes – term describing new cartilage cells
- Synovial Fluid – made by the cells that make up the lining of the joint. In order for new synovial fluid to manufactured there has to be an exit of the old synovial fluid. Synovial fluid leaves the knee throughout the mechanical motion of the knee moving. It is imperative to an effective chondroplasty surgery, however it can also be your enemy if you are not able to control the rate at which it is circulating in your knee after injury or surgery.
1) Physical Exam by MD and conservative treatment with Physical Therapy, rest, medications and possibly injections.
2) MRI or Arthroscope by Orthopedic MD – at this time a chondroplasty may be performed and cells are harvested for possible ACI (Autologous Chondrocyte Implanatation) at a later date if needed.
3) After diagnosing the degree of cartilage changes the doctor, family, therapists and trainers all give you their opinion on whether or not to do surgery. My suggestion is to exhaust all options prior to surgery. Change your training modes and work on your imbalances for 6 months to a year (at the minimum). Knowing you have been 100% compliant and dedicated, then decide to do one of the options below.
Injections or Drug Options
- Viscosupplementation with Synvisc Injections or other Hyaluronic Acid substances– If you do in fact have Arthritis this series of injections can be given to help restore joint fluid for improved joint cushioning
- Steroid Injections – Directly addresses the active inflammatory response to the damaged area; this may be required post surgically to help control swelling
- Glucosamine – Not approved by FDA but may create a better environment in the joint for cartilage
- NSAID’s – These are usually taken for a period of time during first onset of symptoms, during acute aggravation, or post surgically to help control swelling
- Microfracture – this is usually performed if there is significant arthritis from loose bodies; tiny holes are drilled to promote healing and scar tissue building on the articular cartilage. Since hyaline cartilage does not have a blood supply, the drilling goes into the bone to create bleeding and a clot formation for collagen to create a small “tarp” over the damaged hyaline. Limitations to this surgery are that you are not replacing cartilage with cartilage and it will eventually degrade with time if you continue the same training habits.
- Osteoarticular transfer system (OATS) – Also called mosaicplasty; though OATS has had early clinical success, long-term follow-up is essential for a full evaluation of its effectiveness. Limitations of the technique include the inability to deal with large and deep osteochondral defects, limited availability and possible damage to donor sites, non-filled spaces between the circular grafts and incomplete integration of the donor and recipient cartilage.
- Osteocondral Autograft / Allograft – describe a variety of techniques that takes a small piece of cartilage and bone from one area of the knee and put it in the area that the cartilage is missing. This technique can be very effective for small areas of missing cartilage. An osteochondral autograft can often be performed by arthroscopic techniques, but sometimes requires an open incision on the knee. An Allograft procedure takes the cartilage from a cadavers knee and places it in the damaged region.
- Autologous Cartilage Implantation (ACI) – applied to patients between the ages of 15 and 55, with little or no additional damage to the knee-joint. These are patients who do not have enough knee damage to need a total knee replacement, but who are experiencing considerable pain that may be impairing their quality of life. Large “dime to quarter” shaped lesions on the joint surface must be observed to want to take the plunge into a surgery requiring this rehabilitation length. This procedure consists of two surgeries. The first arthroscope involves diagnose the damage, measurement of the area that is damaged, and to collection the 200 – 300 mg from an area of the knee that is not weight-bearing, usually the femoral condyle. The tissue sample is then sent to Genzyme Tissue Repair, where chondrocytes are separated from their surrounding cartilage and cultured for four to five weeks, generating between 5 and 10 million cells. The second step is to implant the cells into the damaged region and smooth the surrounding living cartilage. The rehab for this procedure is at least 9 months to a year.
Scared yet? Not only are these procedures temporary solutions but there are no guarantees that they will get you back to your previous activity level. Many of my clients have been dissatisfied with the outcomes of the surgeries. I believe this is mostly due to lack of disclaimers from all parties (doctors, insurance companies, therapists, family). You can’t blame the doctor though. He has 5-15 min to counsel the patient on whether or not to go through with this surgery. The patient who is going to go through with a cartilage surgery must have realistic goals and must have exhausted all other options. That is why the Physical Therapist must be an active participator in communicating with the patient and MD and in coaching the patient with their activity modifications.
I could probably write a dissertation on the rehabilitation guidelines and considerations to all of the above procedures. The most important factor in successful treatment is to listen to your body. This requires making each progression of activity a research project. Test your injury and body, then wait for the response. Progression of activities involves many variables including but not limited to current fitness level, frequency of activity, type of activity, intensity, training surface, hydration levels, energy expenditure, elevation changes… Now, most of us do not have the time or desire to specifically measure each of these variables but it should be understood that in order to be safe you should only change one variable, A LITTLE, at a time.
How to control your variables in a few simple tips
- I preach the 10% rule – never increase 10% more of any of the above variables the course of one week.
- Get used to riding the bike – it can be the missing link in changing your metabolism and it is a great way to strengthen your heart, core, and lower extremities with low impact.
- Don’t be tempted to run hills just for the extra calorie burn – too much, too soon will cause overuse injuries.
- Use a training log if you are attempting a distance event like a 5K, 10K, marathon, triathlon, or century ride.
- Cross train using HIIT (High Intensity Interval Training) and body weight exercises for a more balanced body.
- Do Yoga if you are tight and Pilates if you are flexible – there may be some cross over here but in general this this is the case
- Train on a soft surface if possible – trails, gravel, rubber – avoid concrete and asphalt
NY Times Article on Early Arthritis
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