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Viewing 1 - 5 out of 5 Blogs.
So far we have discussed non-operative at home cartilage solutions, the non-operative cartilage remedies you must get from a doctor and a surgical technique for small cartilage lesions called micro-fracture.
As we discussed last time, micro-fracture has good outcomes for small cartilage holes, and doesn’t burn any bridges for future cartilage work, if needed, but fills in the defects with “scar cartilage” called fibro- cartilage.
The next cartilage “fix” is called OATS. No, we are not talking about multi-grain here. OATS stands for Osteoarticular Transplant System. Essentially, we take plugs of cartilage and bone from a part of your knee that does not bear weight and transfer it to the area of cartilage wear that does bear weight. It’s like robbing Peter to pay Paul….except it is in the knee. The beauty of this procedure is that we transfer healthy “hyaline” cartilage instead of the fibro-cartilage that grows after microfracture.
We have instruments that literally take a plug of cartilage and bone out en bloc and then transfer the whole block to the new site and tap the plug in. This technique works best in small cartilage holes in the femur (thigh bone) and less well in the tibia (shin bone). It is not a great solution for the knee cap.
Multiple plugs can be used in the same cartilage hole. When this is done it is called “Mosaicplasty.” The outcomes of the OATS procedure seem to work best in knees that are less than 50 years old.
Again, as with microfracture, the rehab from this procedure is long, with six weeks on limited weight bearing and three to six months of rehabilitation prior to returning to all out sports. The purpose of this procedure is to provide pain relief and improve function when a knee replacement is not warranted.
Tags: Knee Osteoarthritis
Here's the third installment in my series on treatments for cartiage issues in Masters athletes. In this installment, I explore "microfracture."
Well Masters athletes, when conservative measures do not relieve the pain and swelling of damaged knee cartilage, there are several techniques for cartilage repair. The important factor to remember, however, is that cartilage is inherently avascular (it has basically no blood supply), and blood is vital for repair of any tissue. When it comes to cartilage you are essentially born with what you are going to have for the rest of your life. The type of cartilage you are born with is called “hyaline cartilage.”
One method for filling in lost cartilage is called “microfracture.” When this technique is successful the “hole” in your cartilage is replaced with “scar cartilage.” This type of cartilage is called “fibrocartilage.” Fibrocartilage fills in the gap in your native knee surface, but the material you grow is not as biomechanically sound as your original cartilage.
The microfracture technique essentially uses your body’s own blood stem cells (cells that can become any cell) to grow the scar cartilage. The stem cells get to the hole in your cartilage through small holes your surgeon makes (microfracture) in the bone underlying the bad spot in your cartilage.
Microfracture is normally performed by first examining your knee with an arthroscope (camera).The area of cartilage loss is prepared with special instruments called curettes in order to make the side of the hole straight up and down like a canyon. An awl is then used to make several small holes in the bone to allow the bone marrow containing stem cells to fill the canyon. This bone marrow forms a clot and over the next 6 months will become scar cartilage.
This procedure is appropriate for small holes (smaller than 2 centimeters) in cartilage and works best for younger people. If the procedure works, 80 percent of patients report good to excellent results even 11 years out. If the procedure does not work, it does not burn any bridges for future cartilage procedures.
Tags: Treatment Osteoarthritis
This is the second installment in a multi-part series on cartilage...
A little help from your doctor
When you have been treating your knee or hip pain yourself and getting no relief, it is time to seek medical care. You must be careful, however, that your sports doc understands that you are a Masters athlete and does not simply tell you to act your age. Many docs are as behind in their expectations of aging athletes as those people you meet who think you are crazy for pushing yourself so hard. If you can’t get your doctor to treat you like the athlete you are -- look around. This sounds harsh but as one of the only sports docs focusing both research and clinical time on the care of the Masters athlete I know it is true.
1. Joint Injections
Two main types of joint injections are given for arthritis pain and swelling. These are steroid injections and joint lubrication. Steroid injections have been around a long time and consist of injecting the joint with a mixture of numbing medicine, such as lidocaine or marcaine, and steroids. The point of this injection is to decrease the pain and inflammation of arthritis. Although used commonly, these injections usually last an average of three weeks and most physicians will give only three a year to any joint. I tend not to use steroids unless my patients have acute, excruciating pain.
I prefer to use joint lubrication with a class of injection called hyaluronic acid. There are currently five of these on the market. Four are purified from the comb of roosters and the fifth is grown in bacteria and then purified for injection. The hyaluronic acid works to decrease inflammation and lubricate the joint. It causes the joint lining to secrete substances that feed the remaining cartilage. Hyaluronic acid injections, or the chicken “stuff,” as it is referred to by many of my patients, works best in early arthritis and can be effective up to six months or longer. They are given once a week for three to five weeks and can be repeated every six months if patients receive significant relief. Using hyaluronic acid injections and having patients strengthen their quads, I have returned many athletes to their sports, which have included an ultramarathon and skiing in Vail.
2. Joint Bracing
As the cartilage and then bone wears down inside the knee, your leg will often change from straight to bowed or knock kneed. Braces can unload the affected side of the joint by pushing on the opposite side and effectively straightening the leg again. For instance, if you have arthritis on the inside or medial side of your knee and develop bow legs, the brace will unload that side by pushing against the outside or lateral side of the knee. The problem with knee braces is that they only work if they are worn daily, and many people simply put them in the closet. These braces are custom braces made especially for you and must be ordered by your physician. The stretchy knee sleeves you buy in a pharmacy are not effective in unloading the knee and are not what I am describing here. Some of my patients like the sleeves, because it makes them more aware of their knees and they feel more stable. For many sports docs the jury is out on the use of knee braces for arthritis. Many of you may not want to admit that you need them. The fact is that for many people they unload the joint sufficiently to allow less painful activity and increased stability.
3. Arthroscopic joint debridement
“Washing the joint out” by surgically removing loose tissue or debris in the joint with small camera and instruments through tiny incisions has not been found to be effective for long-term treatment of arthritis pain. The only true indication for arthroscopic surgery with arthritis is if the person has mechanical catching or locking (feels like popping, snapping or sharp pain) due to a torn meniscus. Arthroscopic surgery is useful if loose bodies (pieces of cartilage or bone that break off) are getting caught in the joint. The surgery will eliminate the mechanical symptoms, but will not touch the aching pain of arthritis. I always make this distinction to my patients.
You can read more about these suggestions at the orthopaedic surgery web site: www.aaos.org
Next time: Surgical interventions for cartilage gone bad -- microfracture
Tags: Cartilage Arthritis
This is the first installment in a series of blogs about cartilage. If any of you road warriors were looking for an Orthopod around town early this month you may have been out of luck. Many of us were playing hooky and attending our annual meeting in San Francisco. This annual event is a time for old friends, peers and even rivals to come together and share the latest advances in musculoskeletal research. The next several blogs will cover a hot topic at this meeting -- cartilage care.
Aging cartilage is a big problem in the general population, but it can be especially vexing for the Masters athlete who has no time nor inclination to be slowed down by the pain or swelling that often accompanies cartilage that is “running out.”
Cartilage is normally the glistening, smoother than ice, biomechanical wonder that lines the ends of our bones -- until it starts to break down. Technically, the definition of cartilage wear is osteoarthritis. Yes, I said the awful word. For most of you this cartilage break down is most problematic in the knees and hips.
These cartilage-care blogs that I'm going to write will cover the following topics:
1. Do it yourself cartilage care.
2. Help from a friend…your doctor.
3. Surgical interventions for cartilage gone bad
4. Microfracture
5. Cartilage transplantation
6. Natural and synthetic plugs
7. Joint replacement
First, do it yourself cartilage care,Caring for your knees and hips begins at home. The following is a short list of treatments you can try on your own.
1. Heat
In the morning or prior to exercise when you are trying to loosen up your tight joints heat is a good fix. A slow steady application is the best way to get your circulation going, relax your tight joints and get ready for activity. There are a variety of ways to accomplish this -- from heating pads, hot water bottles to thermal wraps. In general, I prefer the thermal wraps. Several companies make these but the concept is the constant application of approximately 104 degrees of heat over time. Some of these wraps last up to 12 hours and are perfect for getting on the go (versus a heating pad that leaves you plugged into the wall). Although they may feel warm and definitely smell funny, the heating gels that you rub into your skin do not reach deep enough to increase the circulation around your joint.
2. Ice
After activity, at the end of a long day or anytime your joints ache, ice is an excellent remedy. Not only does this simple solution calm the inflammatory process going on in your knees but it confuses the pain pathways and decreases pain. A minimum of 20 to 30 minutes is necessary. Apply the ice pack or simply a bag with ice onto a thin towel over your joint. Our skin gets thinner with age and this will prevent damage.
3. NSAIDS (Non-steroidal anti-inflammatories)
Now I know most of you will say that you are not “pill people,” but this class of drugs does not simply mask the pain but actually treats the source. Before you take these suggestions you should make sure with your doctor that this class of drugs is all right for you. This is especially key if you have stomach problems. In general, these medications are taken several times a day and take several days to build up a therapeutic level in your blood.
4. Do resistance training!
The key to healthy knees is strong quads and the key to healthy hips are strong cores and buttocks. If you are a typical Masters athlete -- or at least like the many I see each day in my practice -- you do your sport and little cross training or resistance work. All yes, all -- of my patients with cartilage wear are sent to the gym to lift with their quads, cores and butts. This will improve your game and keep your joints healthy. Note: if your knees hurt, especially in the front, NEVER do another knee extension. This exercise loads your kneecap 10 times whatever the weight is you are lifting.
5. Active Rest
If you have pounded out an intense workout and your joints are sore, rest them. This does not mean sitting on the couch for several days. Instead get on a bike and spin, row, use the elliptical, workout your upper body alone one day. Rest is great -- when it is active.
Next time: A little help from your friend, your doctor
Tags: Knee Osteoarthritis
Is aging a number, a feeling or an inevitable biologic process we can't alter? Much of what we know about the aging process has come from studying sedentary people. The problems typically attributed to aging have less to do with actual aging than the sedentary way that more than 70% of people in this country choose to spend their lives. This sedentary living results in 35 chronic diseases that kill more than 250,000 people a year in the U.S. This is many times more than any bacteria, spinach or bird flu out break. It is our couches that are not only aging us but killing us!
It occurred to me that in order to understand the true nature of musculoskeletal aging that we had to eliminate the variable of living a sedentary lifestyle& only this way could we answer the question of "What are our bodies really capable of if we aged the way we were designed for -- actively?"
For this reason I started studying the Senior Olympians. This group of active agers consistently exhibit high levels of functional capacity and a high quality of life. I wanted to know why the 50-year-old male winner of the mile sprint was capable of finishing in 4:34 or why the 70-year-old winner still can blow away many sedentary people half their age by running a mile in 7 minutes.
I began looking at performance times of the top 8 finishers in every track distance from 100m to 10K from age 50 to 85 in the 2001 Senior Olympics. Would there be any kind of pattern to how we age? When does biology take over no matter how active we are?
What I found amazed me. Masters athletes' performance declined less than 2 percent per year for both men and women from age 50 to 75. This was true for the sprint distances as well as the endurance distances.This means that you could put a 50 year old and a 70 year old in the same race and no one gets lapped.
After 75 years old, however, something happens. The slow 2 percent decline in performance times suddenly becomes more than 8 percent decline per year. Why does performance plummet? Is it the cumulative factors of loss of muscle mass, flexibility, coordination or aerobic capacity that suddenly catch up with us?
To evaluate this effect further I looked at American Track and Field record holders -- the bests of the best. From age 30 to age 50, there is less than a 1 percent decline in performance. From age 50 to age 75, this increases to less than 2 percent and after 75 years old, there is again a sharp decrease in performance.
There are many reasons for these observations and maybe you have experienced them yourselves. In the next several blogs I want to talk about these reasons and how you can stay at the top of your game or race for as long as you can.
If you want to read the full study it will be coming out in March in the American Journal of Sports Medicine. It's also attached here as a PDF file.
Tags: Age
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