Marathon Medicine

It’s that time of year again. Thousands of people will take to the streets of our nations capital for what is arguably the mass participation sporting highlight of the year. The London Marathon, or to give it it’s correct marketing title the (Virgin Money London Marathon 2017).

The winter training has been done, the miles and miles of pounding the tarmac, the Rhino suits dusted off. Every runner is now ready for 26 miles of fun / pain (delete where appropriate)weaving around the streets of London .Today will ultimately be a great day of achievement for most of the people taking part and for the hundreds of charities set to benefit from the efforts of so many.

Sadly for some though those miles and miles pounding on the roads through the winter will have taken their toll. For some the aches and pains will be harder to shake off. Runner’s knee and other soft tissue conditions can be difficult to diagnose and treat, hopefully the following may give you some information that can help you get back on track again…

Overuse of your knee joints, also known as repetitive injury can lead to a variety of knee conditions. These usually occur due to localised inflammation and irritation to the ligaments and tendons around the knee joint.

Modification in activity including rest combined with physiotherapy usually helps. However, if the problems persist, surgical treatment may be necessary.

Here’s a look at some of the common knee conditions causes by knee overuse injuries.

Jumper’s Knee (Patellar Tendonitis)

When you experience pain to the front of your knee just below your kneecap or patella, it’s a sign of jumper’s knee. The pain may become severe or stay the same affecting any activity you to indulge in.

Detecting it early is crucial. Simple physiotherapy usually helps in curing the condition. Some patients even benefit from simple knee supports. However, if the situation does not improve in spite of good physiotherapy, surgery or injection therapy may become necessary to help you get back to your usual routine and activity. If you experience pain at the front of your knee.

Iliotibial Band Friction Syndrome (ITB Syndrome)

This is a common occurrence in runners and other activities like cycling and walking. It often occurs when the intensity or duration of activity is increased. Symptoms include pain around the knee and swelling during/post activity.

Usually, an expert physiotherapist will be able to treat your condition. Some athletes will benefit from the use of equipment such as foam rollers to help massage the muscle. However, in rare cases, surgical treatment might become necessary.

Runner’s Knee (Patellofemoral Pain Syndrome)

The pain in the joint between the kneecap and thighbone is patella-femoral syndrome. This is the most common cause for pain at the front of the knee. It could be caused by knee overuse injuries.

When you are running, the knee is under a lot of stress. This may lead to your kneecap rubbing against the thighbone leading to irritation and ache.

The major symptom is pain around the kneecap. The pain begins slowly, and gets worse if you indulge in a lot of activity or sit for a long time. You may hear grinding or clicking noise when bending or straightening the knee. The knee may feel weak as well.

More often than not, rest and rehabilitation physiotherapy should suffice. Physiotherapy includes correction in alignment or gait problems and improvement in the strength and balance in thigh and leg muscles. If there is no improvement with physiotherapy, and adjuncts such as knee supports surgery may become necessary.

As always if you are suffering from pain around your knee it is always worth getting advice from your physiotherapist or my knee doc.

Cartilage tears

Basics


Each knee has two menisci. They are commonly called “the cartilages”. There is one on the inner (medial) side of the knee and one on the outer (lateral) side of the knee. They are C or crescent-shaped and serve to cup the thigh bone (femur) as it sits on the shin bone (tibia) to improve the “fit” of the joint.

The main role of the meniscus is to spread the load being put through the two joint surfaces, thereby protecting the joint surface cartilage. They act as shock absorbers of the knee.
The menisci are important. A torn meniscus does not work properly, instability and early wear in the joint may occur.


Diagnosis and Treatment


Once the diagnosis of a torn cartilage (meniscus) is made you may need an operation to treat it, as it is uncommon for these tears to heal.
Symptoms from small tears can settle down, however, over a few weeks. If symptoms last longer than this, surgery is often needed. Larger tears usually need surgical treatment.
The operation performed will usually be a knee arthroscopy or “key hole” surgery.
Depending on the nature of the cartilage tear, it will either have to be repaired, or trimmed to a smooth edge (a partial meniscectomy).


Partial Meniscectomy


More commonly the torn part has to be removed, a procedure called a “partial meniscectomy”. This is done using special instruments through keyhole incisions at the same time as the knee arthroscopy. The amount of cartilage removed depends on the size of the tear. As little as possible will usually be taken out, trying to leave a smooth stable edge of cartilage behind which will still function as a “shock absorber”.


Meniscal repair


A small number of meniscal tears are suitable for repair. If a tear is treated soon after it occurs and the tear itself lies in the outer part of the meniscus, where there are tiny blood vessels, it may be suitable for repair with special sutures or anchors.
In general this is only considered in the relatively younger age group for a number of technical reasons. Over the age of 30, we know that the chance of a meniscus tear healing is reduced.

L.I.A Surgical Technique

Does loosing weight help with knee pain?

The answer to the question is YES.

Scientific research has shown that even small reductions in body weight can significantly reduce the symptoms of joint pain.

Research has shown us that a 5% to 10% reduction of body weight can dramatically reduce joint pain and improve your ability to exercise.

If you are overweight try to look at this as a positive, you can help yourself.

No one is suggesting that losing weight is easy. Weight loss is difficult when you have bad joints; however, there are ways to exercise that do not place too much stress on the joints of your body.

Diet is also important and getting support from your family doctor, dietician or nutritionist can help.

These positive lifestyle choices will have additional health benefits too.

Exercise for Joint Pain:
Exercise is important for people with arthritis here are some examples you may wish to consider:

Pilates:
Pilates is a great way to strengthen the important muscles in the body (the core) in a low-impact, safe manner. Pilates has become a popular tool for injury treatment and prevention even with professional athletes. Pilates is safe for the joints.

Aqua Aerobic:
Working out in the water is  a way to perform normal activities with less impact compared to working out on land. Water workouts can involve aerobics, walking, jogging or just about anything else.

Swimming:
Swimming is great exercise full stop! With swimming, your joints are supported by the water, which can ease arthritis pain.

Cycling:
Cycling is a low-impact exercise, but the motion of cycling is stimulating for the cartilage within a joint. Cycling gives a good muscular and cardiovascular workout and loosens up stiff joints common in people with arthritis.

Weight Machines:
Training with weights can help strengthen muscles and is also an excellent way to stimulate bone health.

Walking:
May not be the best workout for those with arthritis but walking for exercise is certainly better than no exercise at all. The WHO recommend 10,000 steps a day! Try Nordic walking to work the arms and give some support to the knees


Get Out and Exercise

Exercise has been shown to be useful for patients with arthritis both before and after major surgery.

Seek advice from your family doctor, local gym or physiotherapist on starting an exercise programme to help manage your knee pain.


References: Rooks DS, et al. "Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty." Arthritis Rheum. 2006 Oct 15;55(5):700-8.

Knee pain - assessment - NICE CKS

Knee pain - assessment - NICE CKS

Getting fit for surgery

How can I get in the best condition before knee surgery?

Going through major surgery is like running a marathon. There are a number of things you can do to give yourself the best chance of a good recovery with minimal complications.

•Nutrition

A good diet with plenty of fruit and vegetables as well as proteins can help wound healing and also gives you energy to recover from your surgery, meaning you get home and back to normal life sooner. 

•Physical fitness

Exercise and any form of  physical activity you do will mean your body is as fit as possible before the surgery.It might be difficult to exercise due to the problem which requires surgery,  but try to find ways of introducing some form of exercise into your life. Even 15 minutes of walking or on an exercise bike is much better than not exercising at all.

•Losing weight

Increased size makes the anaesthetic and surgery more difficult with a higher risk of having heart or breathing problems during or after the operation. There is also a greater chance of bleeding, wound infection and developing blood clots in the leg. It is important to try to lose weight before your operation to reduce these risks.

•Smoking

Stopping smoking 4 weeks before your operation helps your wounds to heal but also lowers your risk of breathing and heart problems around the time of your operation. Even stopping smoking up to 3 days before surgery allows more oxygen to be transported in the blood stream. 

•Cutting down on alcohol

If you drink more than the recommended daily average (2 units for women and 3 units for men) you are at increased risk of complications around the time of your operation. Alcohol withdrawal, dehydration, infection, heart problems or bleeding. 

If you need help with any of these speak to your doctor for more advice.

Alternatives to knee replacement for early osteoarthritis

Knee re-alignment (osteotomy)

Osteotomy literally means "cutting of the bone." In a knee osteotomy, either the tibia or femur is cut and then reshaped to relieve pressure on the knee joint.

Knee osteotomy is indicated in early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting the weight off of the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in the arthritic knee.

Osteoarthritis can develop when the bones of the leg do not line up properly. This can put extra stress on either the medial or lateral side of the knee. This extra pressure can wear away the articular cartilage that protects the bones, causing pain and stiffness in the knee.

Successful knee osteotomy surgery should:

• Transfer weight from the arthritic part of the knee to a healthier area
• Correct knee alignment
• Prolong the life span of the patient’s own knee joint

A successful osteotomy may delay the need for a joint replacement for several years. Another advantage is that there are no restrictions on physical activities after an osteotomy – patients will be able to comfortably participate in their favourite activities, even high impact exercise such as football and tennis.

Osteotomy does have disadvantages. For example, pain relief is not as predictable after osteotomy compared with a partial or total knee replacement. It can take slightly longer to recover from an osteotomy procedure than a partial knee replacement.

Because in the past results from total knee replacement and partial knee replacement have been so successful, knee osteotomy surgery had become less common. However it is gaining in popularity as more research is showing good long-term results and more is understood about the importance of preserving the patients own knee.

Osteotomy remains an option for many patients’ especially younger adults with painful osteoarthritis of the knee.

Which patients could benefit from knee osteotomy?

Knee osteotomy is most effective for fit, active patients who are 40 to 60 years old.

The patients should not be smokers.

Good candidates have pain on only one side of the knee, and no pain behind the patella. Knee pain should be brought on mostly by activity, as well as standing for a long period of time.

Patients should be able to fully straighten the knee and bend it at least 90 degrees.

Patients with rheumatoid or inflammatory arthritis are not good candidates for osteotomy.

The operation

A knee osteotomy operation typically lasts between 1 and 2 hours.

The surgeon makes an incision at the side of your knee. They will plan out the correct size of osteotomy using X-rays before the operation. Guide wires are inserted with X-ray guidance to mark out the angle and depth of the osteotomy. With an oscillating saw, the surgeon cuts along the guide wires, and then slowly “opens” up the osteotomy to a pre-determined distance. The surgeon then inserts a plate and screws  (Tomofix ©) to hold the bones in place until the osteotomy heals.

This is the most commonly used osteotomy procedure in the UK, and is called an opening wedge osteotomy.

After Surgery

In most cases, patients stay at the hospital for 1 to 2days after an osteotomy

After the operation, patients may have a knee brace for protection while the bone heals.

The patient will most likely need to use crutches for a few weeks.

About 6 weeks after the operation, X-rays will confirm if the osteotomy is healing and patients can usually begin to return to normal activities over the following months.

Complications

Although the risks are low, the most common complications include:

• Infection
• Blood clots
• Stiffness of the knee joint
• Injuries to vessels and nerves
• Failure of the osteotomy to heal (increased risk in smokers)

Conclusion

Osteotomy can relieve pain and delay the progression of arthritis in the knee. It can allow a younger patient to lead a more active lifestyle for many years. Even though many patients will ultimately require a total knee replacement, an osteotomy can be an effective way to buy time until a replacement is required

References

Ortho info . American academy of Orthopaedic Surgeons