Watch this video of Mr Mark Jackson, Consultant Orthopaedic Surgeon specialising in knee pain discussing ‘Common Knee Injuries in Runners’.
This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.
Mr Mark Jackson is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic specialising in knee surgery.
So just to introduce myself, my name is Mark Jackson. I work as a Consultant Orthopaedic Surgeon and am now predominantly a knee specialist.
I get referrals from across the country, predominantly through general practitioners, physiotherapists, A&E departments and other surgeons. This can involve treating and assessing patients of all age’s right from the age of 12 up to no limit upper limit really, I often see patients well into their 80’s and 90’s. Children who are under the age of 12 tend to be looked after more through the pediatric system.
I am based predominantly here in the Sports Surgery Clinic. I also work a little bit in the Blackrock Clinic, but my practice is then split pretty much down the middle between looking after patients with sports-related injuries and issues, sometimes we call these soft tissue injuries and those that are more degenerative in nature which for the main means problems with arthritis.
So just to go through a few aims of today’s talk, clearly, we would all like to look like the runner on the right here but I just want to give you some basic anatomy so that we can understand the common conditions that we deal with, go through some of the more frequent conditions that I tend to see in the running population, explain often what a role of a knee surgeon can be and give you then a walkthrough and a talk of some examples of patients I have seen in the last few weeks, then just finding a few general tips and advice for people out there who are currently running or perhaps wondering about their injury.
Anatomy is key to any surgeons life and we need to know this in a lot of detail, but just basically if we look at the picture on the left hand side here this is a picture of a knee from the front with obviously all the skin and fat removed and we can see a few things that we may just touch upon today.
The top is the muscle the quad muscle, quad meaning four so there are four bellies of muscle if you like that blend together to form a quadriceps tendon that is seen in this area here blending onto the top of your kneecap and then below the kneecap is the patellar tendon attaching onto the top of your shin bone here in the tibia.
This whole area is called the extensor mechanism – a very common source of pain in runners. The iliotibial band we hear an awful lot about and that’s this structure here but it extends a lot higher than this right all the way up towards the pelvis and if we look at the structures then on the right with a lot of muscular and soft tissues now removed we are going to be seeing the bones which as we mentioned the tibia being the shin bone, the femur which is your thigh bone, the kneecap here is the patella is reflected out of the way just for the picture.
We can see the joint surfaces which are usually very smooth and have low friction. We see ligaments in the middle so we hear a lot about the ACL the anterior cruciate ligament and then in between the bones there are these things called the meniscal cartilages and you have got one on each side of the joint. We will touch upon a few of these issues as we go along.
If we look at these pictures, the picture now on the left-hand side of the screen is the dissected cadaveric specimen with the knee opened up. Again we see the joint surface here this lovely, smooth, glistening surface. This area here under the LFC is the lateral side if they need the later thermal condyle, this is how it should look.
On the inside of the knee on the medial femoral condyle, there is a patch here somewhere developing, not too bad but it is certainly happening in this specimen and the ligaments in the middle. If we were to put a camera in the joint down here and have a look, this is what the viewers get in our keyhole surgery procedures, this is called an arthroscopy. The camera there shows us the meniscus here sitting wedged in between the surfaces and again in this example here this is completely normal with lovely white smooth articular joint surfaces
The last picture on the right-hand side again shows how these meniscal cartilages one here, one here, wedged in and interposed between the weight-bearing portions of the joint.
It’s important just to understand the differences when we talk about the term cartilage. The meniscal cartilage is often referred to as torn cartilage. So if someone says they have torn cartilage, they’re referring to these things here meniscal cartilages.
The joint surface cartilage we often refer to as chondral, or articular cartilage, and that’s these white smooth surfaces.
Half of my work I mentioned is on sports-related issues and soft tissue injuries. Just to give you a few pictures here the top three pictures of keyhole surgery is looking after meniscal cartilage damage, so here is the tear and this is when we removed it. Here we’re doing some stitching and repair of cartilage and things can get quite complicated. We tend to sometimes offer this in very specific indications in sports injuries only.
The bottom three pictures are maybe more the ligamentous type work we might have to deal with, with the middle picture at the bottom being a very typical torn ACL, or anterior cruciate ligament. Once we’ve cleaned it out, we put in a new one in for patients who are desiring a return to their sports, in particular, it would look like this and this would be a before picture, and after picture when we reconstructed and made a new ligament.
Then finally this last picture on the left is when we have to open surgery for complex injuries when somebody has essentially dislocated their knee and tore apart lots of these structures, we’re talking about.
Then the other half of the work will be the more degenerative and arthritic problems. Just a few examples here, what we might end up having to do for people, top left are the two components of what we call a partial or half knee replacement. This is a full total knee replacement. This would be somebody who’s having to undergo another knee replacement so this is a revision total knee replacement, and this is a procedure called an osteotomy.
This is a younger person with arthritis that we’re trying to delay this individual getting a knee replacement, but don’t assume all these people are old – plenty of these patients we see are in their 40s and 50s. It is not infrequent that we’re doing new replacements on people at that age. Most however are going to be into their 60s and 70s.
How common is a runner’s knee injury? The answer is extremely. You go to any race, you are going to see if people are like in these pictures all taped up wearing straps and bandages. This article here is from the American Journal of Sports Medicine, which is probably our most respected journal within orthopaedic surgery and sports sciences.
It looked at a two-year study on 300 runners who were initially uninjured and followed them up respectively over two years. They’re aged between 18 and 60 and running for at least 10 months per week, and at least one overuse injury was sustained in two-thirds of these individuals over that two year period, with at least half of those individuals getting more than one injury.
|The knee was the commonest site of injury, with again almost 30% of all those injuries being at the knee, and the patellofemoral region of the joint, which we mentioned being extensive mechanism was the most common. The most frequent group that were injured were the amateur and inexperienced athletes, the female sex and the middle-aged man.|
If you have picked up an injury and you have a problem, what tends to happen next? People will discuss usually with friends, their family, maybe some fellow runners and people who have had similar experiences and what did they do.
The next step might now be for people to pick up their mobile phone and type things into Dr Google and see what their advice is there online. Maybe they decide to take a break from running for a bit and see what happens, see a physiotherapist, maybe some treatment has begun. If things go well and things settle down, fine, but if not, maybe then is taken further. Maybe a sports doctor gets involved, maybe patients go straight to their GP. Then obviously orthopaedic surgeons can become involved too. I would see patients sometimes referred directly to myself, straight from a physiotherapist or even self-referrals, or sometimes we are the very last people to be involved, because everything else has already been tried, tested, and maybe it is found.
When I do see patients nearly everybody I see is going to have had an MRI scan, and that certainly helps me to give the individual the best diagnosis I can possibly give them and give them a guide to what the best treatment options going forward are likely to be.
So one of the common conditions, we won’t go into this in too much detail, these issues here are very, very common. The tendon type pains, quadriceps tendon. The patellar tendon, hamstrings, and these are the issues also commonly seen.
They can be however divided up a bit more simply into two groups. We have the overloading and overuse type injuries, and we have the degenerative type problems and injuries.
The overload injuries are a bit different, they tend to be fine, they tend to resolve – as long as appropriate treatments are initiated, which are generally non-surgical, and these then can be reversed with most individuals attaining a good outcome. They are also in the main preventable. This picture here just shows a schematic picture of a patellar tendon being inflamed, tendonitis being a very common condition.
The degenerative issues however are a bit different – these are irreversible and need a little bit more careful management and advice. Surgery can occasionally play a role. Is degenerative change inevitable? Yes and no – some people are lucky they escape and they don’t seem to get too many problems, but everyone gets older, everybody’s going to get grey hair and wrinkles. I’m afraid people’s joins do start to show you the strains of the ageing process and some just get it earlier in life more obviously than others.
So what is overload and overuse? Well, it can begin really with some risk factors, those are going to be usually patients have some inadequate strength or strength imbalances, maybe they have quite poor running biomechanics and some inappropriate training regimes. Then there becomes this imbalance and it’s the imbalance between what the body can cope with and respond to what it can heal, and against the load that’s being delivered. If there is too much load and the body can’t respond to it, and heal and become accustomed to that new pressures and loads, then there is this imbalance and overload problems can begin
The majority, as we’ve said, are manageable without surgery. Most of them will have no long term consequences with regards to the development of osteoarthritis, but it is important to have somebody guiding individuals, taking on board advice from experienced therapists, and the sports medicine doctor or GP can sometimes help out. Sometimes investigations are necessary, and injections are necessary, maybe we need to rule out other pathology is there an issue with the spine, is there an issue with the hip, are there rheumatological conditions? So there are sometimes further investigations that are warranted but for most that isn’t going to be necessary.
So what is my role as a surgeon? Well, I can be a good cop or I can be a bad cop. We need to obviously assess the condition, we need to usually take a good history, we’ll examine the knee, and see what we find, help them come to a diagnosis. Interpretation of the imaging and giving this context. The radiological reports vary in quality from around the country and from radiologist to radiologist.
It is really just detailing what is seen on the scan and as we say we don’t necessarily treat the scan we treat the man, so we have to put it in context for individuals and explaining what is relevant and what isn’t relevant. Hopefully, though we are able to then guide people and get them back and keep them running, and if we do that generally then that’s the good cop side of things.
However, we also sometimes have to advise unrealistic expectations, bring people back down to earth a little bit, and also counsel on potential long term issues. In some of my role as well as being a surgeon, which is obviously what we’re trained to do, we enjoy a lot of it can sometimes be a bit of counselling and advising that it is time to perhaps stop running.
The challenge that we face sometimes in a runner’s knee is that both of us see it differently, but we have very similar goals – we both want people to be active. We want people to stay involved in the things that they enjoy doing, but we also don’t want to do this at the behest of having long-term problems.
The runner I see is often very anxious about having some time out, wants to obviously improve symptoms and pain, and some patients are often incredibly surprised that they have picked up an injury. There is often an expectation that we’re going to be able to fix everything and have a very quick fix for it, but you may be saying I have a race coming up in four weeks, I’ve committed to doing a triathlon in Barcelona in two months-time.
We also get a lot of individuals in the current day and age stating that they want to be able to keep running because it’s so important for their mental health. From a surgeon’s perspective, I need to make a diagnosis, I need to know what I can offer somebody, and clearly want to give that person the best route possible to their highest possible function, but we do have that responsibility too that we don’t want people to damage themselves irreversibly and warn of potential implications that can occur down the line.
I don’t want to offend anybody here obviously but there are some challenging runners out there. The retired sportsman or woman who is a keen runner can be a difficulty, they may have picked up quite a few issues in the past, they may have had cruciate ligament injuries or reconstructions, they could have cartilage surgery from their teens and in their 20s, and this is now catching up. That can be sometimes difficult to take.
The runner who is constantly injured, going from one injury to another, from the groin injury to the heel injury, to their knee injury – again these are difficult and challenging people often don’t have quick fixes and aren’t necessarily sometimes taking on board some of the perhaps preventative measures that can be instigated.
The weight runner, again, a bit of a challenge, putting a lot of pressure and force on joints and running in my experience for people who are overweight isn’t necessarily the best way to control weight, certainly not in the long term, there’s usually a lot of other things that should take priority, with regards to diet and lifestyle over just being out running.
Running as a physical job can be a challenge, somebody who’s on a construction site all day or someone who’s farming, who is very heavy on their knees, and that expects to be able to run that evening and over the weekend during long distances that can be quite a difficult need to manage.
The inexperienced and new runner, often in their middle ages. They can be difficult because they’re coming into things maybe with a very poor baseline of fitness and they are enjoying their new running, and they’re feeling the benefits of being able to bounce and being healthy and active, and then gets somewhat surprised when they run into difficulty and have complaints and issues that can’t easily be fixed.
Then there is the perpetual knee abuser – somebody who isn’t listening to the advice, is getting sore swollen knees and keeping on going, has an operation keeps on going, has another operation keeps on going. But eventually usually the penny does drop and people come to terms with their challenges.
As a surgeon, one of my roles is clearly who needs surgery? Actually, for runners, it’s relatively few, but there are some specific indications that we can sometimes help with, as we’ve said the majority of injuries in runners can be resolved with a good diagnosis and expertise from a rehabilitation program.
We do need to have some realistic expectations though, and patience is very important as the change in strength, the changing of biomechanics takes time. This is not necessarily just measured with a few physio sessions over a week or two – this can take months and months and it does often require motivation and dedication.
So just to go through a few surgical examples of patients I’ve recently looked after. This is a very elite level runner in fact hoping to make qualifying times from 1500 meters for this year’s Olympics for Ireland and was referred with symptoms of mechanical nature, symptoms of locking and jamming, and overall it’s fairly unusual to see elite-level runners with knee problems.
It’s a somewhat unusual referral, but he had a very clear problem, he had a condition with osteochondritis desiccants, and what we can see here in the keyhole surgery is me retrieving a loose body that’s floating around in the joint, and this has been generated off the joint surface here. When it moves around in joint like this it can get pinched and caught, but as soon as it’s removed the symptoms resolve and he made a very quick rapid recovery and was back running within about three or four weeks, and is now back up to speed and back on track again hopefully for his goals going forward.
This again is a common presentation – a 41-year-old recreational runner, as a physical job. There was no injury, came on gradually and steadily, but he’s now got to the point where he’s had to stop running, pain is interfering with life, maybe sleep, maybe he’s waking at night and he is limping.
When we put the camera in the knee, this is the problem, this is a tear here in the meniscus in between the joint surfaces. However, the rest of his knee is perfect. This is the other half of his knee, with a normal meniscus and normal joint surfaces. These surfaces are normal, so when we take out the tear which is what this picture is here, so this is the before picture and this is the after picture because the rest of his knee is normal, he can have a very good outcome and indeed he did go back into things and settled very quickly.
This is a similar type of issue and there is a meniscal cartilage tear. It is a bit different, it’s more degenerative and again we can clean this up. So this is taken to this, but the difference, in this case, is that there is some joint surface damage starting. We have to take this a little bit more cautiously because there is the propensity for this to still cause a few issues and pains, and if this progresses over the next few years then it could be more challenging for that individual to stay involved in these kinds of impact and running type activities, and as is often the way there are similar symptoms also developing on his other knee.
This would be an overload problem, again recreational runner. We’ve seen quite a lot of that in the last 18 months with people perhaps doing more running, the normal increase in the load, running more days, maybe running frequently, maybe running for longer distances. This is a reaction in the bone, so in this MRI scan this is a view of the knee from the front. This is the femur, thigh bone, tibia here, and in this bit of bone, you can see a white pattern. This is a side view showing the same pattern in the bone. What this represents is bone stress, bone bruising if you like or bone oedema.
This is indicative that this bone isn’t enjoying this new load and is reacting because it isn’t getting a chance to heal. This though is in the background of the knee that otherwise looks good. So again, this is rested and protected, the bone will heal, symptoms will usually subside, but it can take time, and this type of condition can sometimes take at least three months, sometimes longer, before we allow that person to then start to up that load and increase their running again, and in the background need to be seeing a physiotherapist to be working on their strength and seeing if there are some preventative measures that can be put in place before that person returns into their desired activity.
This thing gets a little bit more challenging because this is now significant arthritis in a young age. This individual again has been a regular runner over a good few years, and seems to remember there was an old hurling injury, probably tore his ACL ligament, but didn’t need any surgery at that stage, but he’s now at the point where on the scan that this is a very worn-out joint, and when the camera is put inside the knee, there are areas of bare bone rubbing on bare bone. So this is now 100% game over for this individual. This they have to accept, there is no good fix for this, and running is unrealistic. However, there should be other activities we can get this person into the gym, bike, cross trainers, weight training, and we can then hopefully maintain some good function of years, but we’ll have to accept that there are more major surgeries down the line, and we need to delay these for as long as we can.
Somebody who’s been overweight and running as we’ve mentioned can be a challenge. This individual weighs 120 kilos and is using running as his way to control his weight. However, now he’s getting arthritis in the knee underneath the kneecap here on his scan. He also has a poor program of running, very poor basics and is weak. This is very vulnerable to progress and it won’t be long before other areas of his knee also catch up and start to wear down. This is not again a surgical case, this is just about education, telling people what’s going on, interpreting the scan and giving the expectations going forward. This individual needs to now look at alternative ways to control weight as opposed to the impact of the activities and running.
One final case again premature osteoarthritis again in a very active individual in their 40s who has been heavily involved in doing triathlons and long-distance running over about a 10 year period. This is on the background of having a previous cartilage surgery, about 10 years ago. These are both of the knees, the right knee here is bone on bone with a stress reaction again bone oedema, and the left knee less advanced changes, but this right knee, in particular, is in big trouble, his left knee may settle down. This gentleman has persisted with his running despite being sore, hasn’t really listened to his knees. By the time it comes to get attention and be reviewed, things have really moved on, and again this is an individual who probably will need treatments down the line and it is a matter of not delaying this for as long as we can.
Then we get the serial abusers. This would be somebody who’s very vulnerable to getting problems, a daily runner, someone who every single day goes out running without rest and does nothing else, and has been aware of symptoms over time but is now getting worse, still running though, determined to keep running, not prepared to take time out and rest, and as well as the run will often walk for 10 kilometres a day. So what’s happening now is this person is getting arthritis again similar to the overweight case we just discussed, with the kneecap wearing out in front of the joint, but there’s also a stress reaction and stress fracture here in the inner side of the knee. Although this may settle and improve if he/she doesn’t do this can deteriorate quite quickly into a much more significant arthritic problem. So again, education, not necessarily surgery.
A few hard truths about osteoarthritis, it’s obviously great that our life expectancy and things have improved, but it does bring with it the challenges of osteoarthritis, we as yet don’t have good medical treatments.
This graph at the bottom right-hand side shows how the rates of as we say here the prevalence of arthritis in percentage terms is rising through the age groups, so 40-50, 60-70 and 80. At the age of say 70, 40% of the population have screened for osteoarthritis we’ll find that that’s the case.
Prevalence is different to symptoms. A lot of these people still may be relatively unaware of their symptoms, but if we MRI or X-ray people, there are these findings that are developing, and we can see here the significant increase risk and prevalence in women, as compared to men.
Everybody there has an individualized risk, we are not all the same. There are clear risk factors, first of all, a few here, age, and whether male or female, but the other risk factors here which are independent are obesity, which plays a massive role now in the patients we see that arthritis at a younger age, and also those that have significant prior injuries, and the things we can’t do much about like genetics, you can follow your favourite football team and find that there are players who are just constantly being injured, and some of them seem to go through a massive pretty long career without ever picking up much of an injury.
A lot has to do with genetics, how are your limbs lined up, what are the shape of your bones and joints, how is your collagen made up, what are your ligaments like, are you somebody who’s very naturally loose-jointed which can lead to problems, are you, somebody who’s very tight jointed which can lead to problems, are you a responder to training people respond differently? Some people’s muscle hypertrophy comes very easy, some doesn’t, what are your muscle types? There are lots of genetic factors that will probably play into osteoarthritis in itself, some of which we still don’t really understand. We have to remember the surgical treatments for arthritis are often significant and in general, are not going to be procedures that are going to allow patients to return to their running activity.
So, to get towards the end of the talk, my top 10 tips here for runners would be to stay active, but don’t just do running. To get stronger, get some resistance training going maybe get a good rehab person to evaluate and improve your technique. Please don’t try and use running as your primary weight control measure there are other things you can do, and it is important to recognize that the running may not continue forever or you may pick up an injury, so you do need alternative ways.
Similarly, don’t rely purely on running to manage mental health issues – this is clearly a complicated matter, but if you suddenly find you’re out of running for a period of time that can obviously add into anxiety and mental health concerns.
It’s good to get to know an experienced physiotherapist, usually, unfortunately, there aren’t quick fixes or miracle cures and it is important for individuals to accept sometimes timeout is necessary to try to recover and rehabilitate, and you need to listen to some of the warning signs of irreversible joint damage, so in the main, that’s going to be a lot of swelling after activities, stiffness and pain. If these things are happening, please don’t ignore and get somebody to interpret these symptoms for you.
However, if all feels good, and you are managing your load well in your training, well it’s fine to continue, and people will continue well into their 40s 50s 60s and sometimes beyond, but it’s not for everybody at that age group and we just have to be realistic.
In general, even though I’m a surgeon and it is what we enjoy doing in a way and what we’re trained to do, surgery can often be avoided, and it can be a slippery slope. You don’t want to just be looking for quick surgical fixes and find within a few years things have gotten a lot harder to manage.
In summary, we all have the same goals – we want people to be active, we want them to be healthy and enjoy their sports. Most of these conditions that runners will present us with are not going to necessarily be going into anything surgical, and I do encourage you to listen to your knee symptoms, get them checked out if you’re concerned, commit them to some prevention measures which involve some alterations perhaps in your training, and accept that unfortunately injuries relatively common, and you may need on occasion to have a break and some time out.
At this event, Mr Mark Jackson (MJ), answered questions from our live audience asked by Fiona Roche (FR).
FR: Are supplements beneficial for knee injuries?
MJ: Supplements is obviously a fairly big topic – the common ones that people talk about are going to be things like glucosamine, chondroitin, fish oils and then there are things like turmeric which are sort of a popular one which people are purchasing and trying at the moment.
From a purely scientific standpoint, the evidence for these supplements is pretty weak. People are welcome if they like to try them, some patients I get seem to report that they get some benefit, but scientifically there is no good evidence to show that it slows up the process of wear and tear, rests the process of arthritis or really gives much symptom relief over placebo.
I always tend to say it is up to the individual – they can try it and by all means, they may get lucky and it helps them but I don’t tend to routinely say you must be on this or that supplement. That is the problem with arthritis generally, we don’t have great medical treatments as of yet.
FR: How do you know the difference between normal aches or pains after say a long run if the aches and pains are normal and the warning signs of an impending injury?
MJ: A lot of people might get a few aches and pains – that isn’t necessarily the problem, it’s the degree of pain and the restrictions it causes maybe afterwards. The warning sign in the knee is the knee that reacts badly to that activity that evening and the next day. People may feel that the knee swells within a few hours, maybe you go to bed that evening and waking up with pain, and then coming down the stairs sideways the next morning limping a little bit and then it eases off and then two days later maybe they feel they can run again.
That is a bit of a vicious circle you are getting into. That is what I mean about sometimes listening to the knee symptoms that is your knee telling you there is a problem. I think those are the times I would encourage people to get looked at and maybe get some imaging particularly if there is a lot of swelling and just to make sure you are not running into trouble with significant chondral damage and arthritic issues, but if it is a little ache that doesn’t seem to hold you back too much or doesn’t seem to have like a hangover effect, you are not having to take loads of painkillers and anti-inflammatories, a lot of those can probably be ignored, but it is obviously going to be different from person to person.
FR: Jennifer damaged her patellar tendon three months post-pregnancy. She is not new to running and had no knee issues before. She slowly built up running again 20 minutes wearing a knee trap. How likely are these types of injuries in returning again and any tips on how to avoid them happening?
MJ: Reading the question it is a bit difficult when it is specific to an individual. It sounds like somebody is returning to running after pregnancy. One of the issues with pregnancy is there is obviously a lot of weight gain which puts a lot of stress on the joints and there is also a lot of hormonal changes. Some of these hormonal changes can lead to ligamentous laxity and joint pain in itself and because sometimes a lot of core weakening may happen so with the pregnancy and the stretching of the abdominal muscles and stress on the back, it takes a long time to restore strength in around the core and the glutes. It is not uncommon then that someone even if they have been a runner in the past can return to activity and they are running into a bit of that overload and overuse issue which we talked about in the talk there.
I would think that the predominant thing is to go back to real basic strength and conditioning exercises, work a lot on core. Wearing knee straps I don’t find particularly useful but I know a lot of patients seem to like wearing them. I find it very difficult often to explain to patients what they are doing, the type of straps underneath the patellar tendon and things – I think you are better off going down a goof rehab route as opposed to trying to rely on a strap.
FR: Leanne says her knee hurts when she used to go up and down the stairs but it has now eased, now it hurts only when I lunge. It does ease when I stretch my hamstring and it doesn’t hurt when I run.
MJ: This is one of the commonest knee symptoms for everybody, not just runners, so this is patellofemoral pain, so in front of the knee bone. It won’t think it has anything to do with bicep femoris, which for people is one of their hamstring tendons and I don’t think it will relate usually to the IT band syndrome issues. It is the loading position of the patellar tendon, so that going downstairs is sometimes worse than going upstairs, any single-leg squat, split squats, Bulgarian squats or those kinds of issues and the lunge.
So my feeling on that briefly on the history there would be much more patellofemoral pain, and that can then be the crunching and noises that people get and would be very common in those positions as well, particularly from the patellar tendon joint so the rehab will be focused there.
FR: Bronagh says she is a keen runner, meniscus resection 10 years ago, knee pain has resumed in the last 2 years, MRI is showing Osteoarthritis medial compartmental cartilage meniscal damage. She is recommended to have a uni knee replacement, will she be able to resume running after this?
MJ: Again these are some of those challenging conditions that we talked about there. I don’t know what age this individual is but obviously having had a significant meniscus resection in the past has led to accelerated wear and has now got to what we call unicompartmental advanced arthritis.
It would depend a little bit on the patient’s age. Unicompartmental knee replacement is a good option for day to day life but not for returning to running in my opinion. I do partial knee replacements and unicompartmental knee replacements often, but these implants are not designed for running, they are designed to give people a better quality of life in their day to day routine.
Activity expectations are going to be for walking, hiking, and if they do well then they are into the next level of activity which could be your golf, maybe playing some light doubles tennis and that is as far as I usually recommend people take it.
Obviously cycling, gym work there are things that you can do but actually going out on the road and running with a knee replacement is not going to be advisable. If you have a uni you want that to last and no moving part lasts forever. If you are in your 50’s and getting a partial knee replacement that is a stepping stone to a total knee replacement usually and you want to look after that knee. So stay active but don’t go into those surgeries with a goal of returning to a heavy impact activity like running.
FR: Peter has torn his meniscus in both knees in the past 12 months, can he expect that it is likely to happen again? He is 55.
MJ: This is the degenerative meniscus issue, again often you do find people who have very similar experiences on both their knees. Somebody who has got a meniscal tear on one knee obviously been followed up by a similar problem on the other side. Those issues at 55 are evidence really of a degenerative type process that is going on.
I wouldn’t be necessarily concerned about the meniscal tear itself happening again, you would be more worried about the consequences of the damaging meniscus and the damaging joint, so that would mean getting into problems of arthritis, so in terms of having a meniscal tear happening again I wouldn’t be too worried, it is more the consequences of having the tear in the first place that I would be a little bit more concerned with.
FR: Karen is a 49-year-old runner currently approximately doing 20 -25 miles a week, including speed sessions. She has a history of distance running and very mild knee pain from time to time but it’s not problematic on both knees in the last year. They are making a crunching, grating sound – should she be concerned?
MJ: It would be interesting to do a survey on everyone who is in this talk about crunching and grating from the knees. I can tell you my knees crunch and grate all the time. Almost every knee I examine is going to have some clicks or noises. Crunching and grating in itself can often be very benign and mean absolutely nothing or it can sometimes mean there is a bit of wear and tear, and that is going to be again around the patellofemoral joints around the kneecap, so those up and downstairs clicks and grinds that an awful lot of people experience generally from the patellar femoral joint, so again in the gym the squats, lunges, leg presses put force on the patellofemoral joint and as I said, it can just be quite benign and if it is not associated with huge pain and swelling I wouldn’t be too worried.
FR: Can chondromalacia be treated with surgery?
MJ: All chondromalacia means is soft cartilage and it means chondro is the surfaces of the joint, so soft surfaces of the joint and the common term you hear is chondromalacia patella which is soft cartilage on the kneecap. It is a very umbrella term. It doesn’t in itself mean very much and chondromalacia patella is often talked and it is not usually very responsive to surgery.
In simple terms no, chondromalacia does not usually lead to surgery. It is a process going on of the surface of the joint starting to get a little bit damaged and if it is on the kneecap in particular most sports surgeons would be nervous to recommend surgery for a bit of damage on the back of the kneecap because often it doesn’t change that much, certainly not as much as the rehab probably would.