A 40 year–old patient, Marco, recently came in to see me about his right knee. He is very active and likes to hike and bike the many trails near Portland. He also enjoys running and he used to play soccer in high school and college and considers himself to be naturally athletic. Though Marco no longer plays competitive soccer, he plays recreationally and helps coach his kid’s soccer teams. Marco scheduled an appointment to be seen in my sports injury clinic because he began experiencing swelling in his right knee after running and coaching soccer. It would usually resolve after a couple days, but he noticed over the past 6 weeks that it seems to be persisting and keeping him from fully bending his knee. He reports only mild knee pain and stiffness.
Marco states, “I did have surgery on the knee about 20 years ago to remove part of a torn meniscus due to a soccer injury.”
He is concerned because he really wants the swelling to go away because it is adversely affecting his ability to run. When I examined Marco’s right knee, it had a mild amount of fluid in the joint compared to his left knee. This can be associated with injury or inflammation. We decided to take an x-ray of his knee which showed some loss of cartilage lining the bone where he had surgery 20 years ago. He is experiencing right knee swelling due to inflammation and damage to the cartilage lining the bones of his knee.
Marco asks, “what can we do about this?”
With increasing longevity and many individuals desiring to stay active later in life, we want to be able to preserve our joints and their function. We want to avoid joint related problems that can otherwise keep us from fully enjoying the ability to be active doing things we enjoy.
So, how can we do that?
Just as with physics where objects in motion tend to stay in motion, people that are active tend to stay active. Having daily time set aside for exercise is an important way to stay physically and mentally healthy while preserving one’s joints. It used to be believed that running leads to arthritis of the hip and knee. Now we know the opposite is true. For the majority of individuals, exercise like running helps promote healthy cartilage and joints.
Let’s face it that sometimes injuries (just like accidents) happen. We can’t wrap ourselves in bubble wrap or live by the motto of “nobody moves and nobody gets hurt”. Maybe an injury resulted from a slip and fall, a fun outing, a sports incident, or even a motor vehicle accident. While we realize that things happen and we have to keep moving forward, we can take the approach of trying to play sports and be active safely. Whether it’s working out at the gym and using good form, wearing a helmet when biking or snow skiing, wearing a seatbelt when in a vehicle, or making sure we are not playing through pain, applying basic safety principles to activities can still allow for enjoyment while reducing injury risk.
The weight bearing joints, our hips, knees, and feet/ankles are placed under much stress of standing, walking, and load bearing day after day. Our weight plays an important role in how much loading stress our joints take up with each step. Studies have shown that as little as a 3-5% weight loss can help knee pain significantly. I commonly tell patients that “for every 1 pound of body weight, it is 5 pounds across the knee with each step. If you can lose 10 pounds, it is like taking 50 pounds off your knee with each step. Multiply that by 10,000 steps per day and it’s easier to understand the negative impact being overweight can have on preserving our joints.
We’ve likely heard that some foods can have anti-inflammatory or anti-oxidant effects. It is important to recognize that some foods that are heavily processed or sugar sweetened are not the best or our joint health. Fruits, vegetables, and healthy fats from nuts or other plant based sources are preferred for their anti-inflammatory effect. While I know it can be difficult to make dietary changes, especially those that might reduce intake of your favorite foods, making gradual changes and allowing yourself the opportunity to still have some of those foods you crave but in moderation can still be a successful plan to reach long term goals of positive dietary changes.
This is a no-brainer. Smoking is awful for us and its negative effect on joint repair and how it promotes inflammation is deleterious to joint healing and joint health. If you smoke, please stop. If you’ve tried to stop unsuccessfully, keep trying as this habit is difficult to break, and the benefits of stopping are worth the repeated effort. Also, there are ever increasing resources and support available to help you overcome smoking.
More and more individuals are becoming aware of the limitations of major surgery like knee and hip replacement when our joints wear out. While these surgeries can be effective at relieving pain and improving quality of life when our knee and hips have severe arthritis, we are realizing the limitations of these procedures and understand that no artificial joint is going to be better than the joint we are born with. There is a lot of interest in joint preservation treatments both surgical and non-surgical. Many of these treatments fall under the broad term of orthobiologics which are typically considered to be natural substances found in the body that promote healing or repair of damaged tissue. Orthobiologics can be bone grafts, stem cells, and can come from the same person (autologous) or another person (allogenic).
There are several non-surgical orthobiologic options for individuals with joint pain, inflammation, and cartilage damage.
—Platelet rich plasma (PRP) is autologous and utilizes the body’s platelets and their growth factors to help promote tendon and joint healing and repair. It can be effective for problems affecting the knee joint, hip, shoulder, and elbow. The platelets are concentrated from the individuals own blood. PRP has been shown to help reduce pain and inflammation in individuals with arthritis of the knee and hip.
—Bone marrow aspirate concentrate (BMAC) takes healing cells and platelets from bone marrow and allows for them to be separated and concentrated and re-injected into the area of joint damage like the knee joint or ankle which can reduce inflammation and promote healing of damaged tissue.
—Alpha 2 macroglobulin (A2M). A2M is a large naturally occurring protein found in blood. It is gaining interest in the treatment of cartilage damage, osteoarthritis, and preventing additional damage after joint injury. There is interest in A2M for knee injuries like anterior cruciate ligament (ACL) tears to reduce joint damage after the injury. It is concentrated similar to PRP by drawing whole blood from the patient and re-injecting it into the affected joint where it can reduce inflammation and catabolic effects while promoting healing through a better joint fluid environment.
—Hyaluronic acid (HA) injections have been utilized for several decades in orthopedic and sports medicine clinics to treat knee joint pain and stiffness associated with mild to moderate arthritis. HA is a naturally occurring substance found in cartilage, skin, and other tissue throughout the body. HA injections can reduce the production of inflammatory enzymes in the affected joint. HA can also work together with PRP or other orthobiologics to help improve joint pain, motion, and function.
For our patient, Marco, after a discussion about the different treatment options for his knee, we decided to drain fluid from his knee and proceed with an injection of PRP and HA. After the injection, Marco rested his knee temporarily, then began resuming his activities that were previously causing swelling. He was able to successfully get back to more running. He also made an effort to lose a few pounds, make dietary modifications, and balance his impact and low-impact training volume. For Marco, this approach has helped him achieve his goals of running more, playing soccer with his kids, and avoiding knee swelling.