Search for tag: "osteoarthritis"

Interviewer: Running from a doctor's perspective, that's next on The Scope.

Announcer: This is "From The Front Lines" with emergency room physician, Dr. Troy Madsen on The Scope. On The Scope.

Interviewer: When emergency room doctor, Troy Madsen, was thinking about running as his main exercise a few years ago, he was concerned about how it would affect his knees. So he did the research like any good doctor would do. And Dr. Madsen, what did you find out?

Dr. Madsen: Well, you know, like you said, my concern in running was, "Okay, great. I'm going to start running more." I said I'm going to run every day, do a couple miles every day, go from there, but in 10 years, I'm going to need a knee replacement. This is what I thought. This was what I grew up hearing. This is what people said. So I said to myself, you know, "I work in medicine, certainly I can look and see what kind of evidence there is for this. Are there any studies that have been done that show that runners have a much higher risk of needing knee replacements?" So the big concern here would be that you run a lot, you wear down the cartilage in your knees, you get osteoarthritis, which is bone on bone, and then at that point, it hurts too much, you need to have your knees replaced.

So it's a tough thing to study. You know, ideally, you would take a group of people and say, "You guys are going to run every day, you guys aren't. And then 10 years, we're going to see how your knees are doing." You can't do that. It's not practical. So you really just have to rely on people reporting how many knee issues they've had. Look at runners, look at non-runners.

Interestingly enough, at the time I looked, there were a few studies that had been done looking at this, and just this month, an editorial came out in the British Medical Journal that addressed exactly this question. So they summarize all the research that is out there. The bottom line is there is no convincing evidence that will tell you that runners have a higher risk of knee osteoarthritis and knee replacements.

The only thing they found, they said, okay, one study showed that in elite runners, they had a higher incidence of osteoarthritis where it was this bone on bone. This was one study that was done in the early 1990s. These were elite runners, meaning runners who had competed in Olympic marathons, and they had a little bit higher risk of this issue. I found studies that actually suggested in runners, they're 50% less likely to have any issues, meaning that maybe this running is actually helping the knees potentially helping build this cartilage up. You know, certainly, if you're having other injuries like ACL injuries or tearing ligaments, things like that, that's a different issue.

But just the whole wear and tear of running or this idea that you're just tearing your knees up, I can't find anything convincing that says, "Yeah, you're tearing your knees up, you're going to get bone-on-bone knees, and then in 10 years, you are going to need a knee replacement."

Interviewer: So had you found evidence to the contrary, would you be a runner right now?

Dr. Madsen: It's a great question. I don't know.

Interviewer: I'm trying to figure out if you're putting your money where your mouth is on this deal.

Dr. Madsen: Yeah, you know, at the time, and I think for a long time, that was my excuse for not running. I'll tell you the reason I ran is because my wife made me commit to run a marathon because we're moving, and that was part of the deal, "If we're moving, you have to run a marathon." I think she thought I was going to say that there's no way I'm going to run a marathon, but I committed to do it, and I've kept running since then. I think partly knowing that, "Hey, you know, this is a great exercise. It's a great sport. It's a great life-long sport. And the whole knee issue, I'm convinced that, you know, based on the evidence I can find that running isn't going to tear your knees up." I just can't find anything that absolutely says, "Yeah, you're going to have lots of knee problems because of this."

Interviewer: What about like somebody's weight or other issues like that? How is that taken into account in these studies?

Dr. Madsen: Yeah, it's tough. Again, these are not ideal studies.

Interviewer: Sure.

Dr. Madsen: I mean, they're small studies. They're combining these studies to create what's called a meta-analysis where you combine data from lots of different studies. I don't know that they can really control for those factors for weight and look at a person's weight. Because you're talking about people who've been running for 20 years, can you account for their weight 20 years ago versus now? What different effects are there? I don't even have an answer.

Interviewer: Yeah, yeah. I would imagine, too, something else maybe to keep in mind. So I think this is good that if running is something that you do, that's great, continue to do it. If it's something you want to do, there doesn't seem to be a lot of compelling evidence it's going to cause knee issues. But I'd imagine it would be smart to be safe and, you know, make sure that you're in with a reasonable weight, and maybe even make sure that you're running form is good, that you're not heel striking and doing some of those sorts of things. Because the runners in the study conceivably would be doing those things.

Dr. Madsen: Exactly. You don't want to force yourself into a sport. You want to make sure your heart is in good shape, that you're going to be able to handle it. Don't just go off the couch and go put in seven or eight miles. Like you said, you've got to consider all those factors. Find a sport you enjoy. But I think the bottom line from this is if you enjoy running, don't tell yourself you can't run or you can't run more because you're going to have major knee problems down the road. I just can't find anything that suggests that's the case.

Interviewer: And since you started years back, when you first started running, when you did this research, you've since run marathons, and how do the knees feel?

Dr. Madsen: Knees are great. Don't ask me that question after a marathon, but today the knees feel good. You know, after long runs, there's always the aches and pains.

Interviewer: Yeah, but not knees, right? It's usually muscular or . . .

Dr. Madsen: Yeah, it's usually muscular, it is. It is not the knees so much. Well, I'll take that back. I'd say usually about mile 24, 25, everything hurts.

Interviewer: Sure.

Dr. Madsen: And I'm telling myself, "I will never do this again." But, you know, you give it a day, you start to feel a little better, and then you're back at it.

Interviewer: And then for individuals that maybe currently run and they're thinking about wanting to run a little bit more, maybe they're kind of in this three to five-mile range, and they're afraid to go beyond that. Again, the research shows that probably not going to negatively affect you?

Dr. Madsen: Exactly. I think that's the big take home. But at the same time, keep in mind that if you're happy just doing three to five miles, keep doing it. You're getting the health benefits. And that's a whole different discussion. But if you're doing three to five miles, three times a week, you're doing great. And if you like it, if you're happy with it, keep doing it. If you want to increase those miles, maybe do a half marathon or something, feel free to do it.

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Tom: You have osteoarthritis? What can you do about that before you require a total joint replacement? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Tom: I'm here with Dr. David Petron. He's a professor of sports medicine. He's a non-operative physician and he works in the Department of Orthopedics here at the university.

David, what options does one have, prior to a joint replacement, in order to treat that pain and dysfunction?

David: Well, ultimately, you want to try to stay away from a joint replacement obviously. And the thing that leads to that is osteoarthritis of the joint, most commonly weight-bearing joints like hip or knee. And a lot of people don't even know what osteoarthritis is, but it's generally the wearing out of articular cartilage, which is that smooth shiny cartilage at the end of bone. So it's more of a wear-and-tear process, and ultimately the joint narrows and you start to get bone spurs, and aching, and stiffness, and swelling. And then really what drives the patient to the doctor is pain.

Tom: Does everyone anticipate that type of wear and tear over their lives, or are just some people prone to that?

David: Some people are prone to it. So there is a genetic predisposition to it. But if you're overweight or you've had prior trauma, that also can predispose you to arthritis. But it's really insidious, so most people are surprised when I tell them they have arthritis because they didn't have an injury, and they said their knee just started hurting and swelling . . .

Tom: Slowly comes on, over time, and it's nagging. And after a while, they just can't take it anymore.

David: And finally they figure out, "Well, I can't run, anymore. I can't do the things I want to do, anymore, so I'm going to go see the doctor."

Tom: So, by that time, I'm assuming they've maybe tried some home therapies. They've taken over-the-counter pain relievers like ibuprofen, or Naprosyn, or even aspirin, and, at some point, maybe those aren't really cutting it and they're not able to do the things that they used to do. What do you offer them?

David: Well, there's really three things they can do that they can control themselves. One is to get the muscles around the joint as strong as possible. So if it's a knee, quadricep strengthening, and usually doing lower-impact activity.

Tom: So that improves function. Does it help with pain?

David: It does help with pain. So if they can increase strength, that helps the pain, really the muscles surrounding the joint are the shock absorber for the joint. So the stronger, the more balanced, the more strength you have, the less likely you are to have pain in that joint.

Tom: So first tip is physical therapy. That's the way to start. And don't go with the old adage, don't use the joint. You know, don't slack off. Don't rest the joint.

David: Well, exactly. That's when people get in a vicious cycle. It hurts, so they quit doing anything, so the joint stiffens. And because they're not doing anything, they gain weight, which makes the joint hurt more, and on and on it goes.

So really there are three things they can control: one, keeping the strength up, two, avoiding high-impact exercise, and the third thing is keeping your weight right.

Tom: Now, by high-impact exercise, I assume you're talking about running, jumping rope, skydiving?

David: Right. Lower-impact things are okay, so usually walking, which can . . . you know, there's some impact with that, but that's usually not too bad. But biking can be a really good exercise for it, or even weight-lifting. So it's usually the high energy things. So, like, if you jump even off the height off the stair step, that could hurt the knee. But if you slowly low that up by, like, getting out of a chair, that doesn't hurt the knee, and you build strength with it.

Tom: So how about running on a treadmill? So for people who like to run, and there are a lot of them, plenty of people don't bike and they love to run, I guess they could switch to swimming, but what about walking or running on a treadmill versus being outside?

David: Absolutely, that can be easier on it. And we actually have a running clinic at the Orthopedic Center, and we, a lot of times, evaluate runners and find that they can be putting too much stress on their quadriceps and not running enough out of their hamstring and their gluts. So they tend to over-stride, which makes them load up the quadricep, which puts more stress on the knee. So sometimes it's something as simple as learning how to run a little bit differently, a lot of time, shortening the stride, and having more of the energy through the gluts and through the hamstring.

Tom: So let's say that they do these things and they're very diligent about the physical therapy, and they lose weight, but they still have pain. What else can be done?

David: There's different injections that can be done. One of the things that can be done that's usually a short-term answer to the problem is a corticosteroid injection. But a lot of times, that can kind of reset the pain. So it can settle down inflammation and settle down the pain so that we can institute some of these other things that we're talking about.

Tom: Now, there are other things besides corticosteroid injections that you have used in the past, I think.

David: Right, there's something called viscosupplements which are more of a lubricant for the joints, so it's like . . .

Tom: Those 50 weight [inaudible 00:04:41].

David: Yeah, that's it. It has a thickness to it, and that's either in a series of one to three injections, and it kind of resets the environment of the joint so that the arthritis doesn't progress as quickly. So there's some evidence to suggest that it may slow down some of the progression of arthritis, but it certainly can help with the symptoms.

Tom: And how long can that effect last if it works?

David: That tends to last . . .

Tom: I guess the question might be: How many patients will respond to those viscous injections?

David: I would say, in general, the less advanced the arthritis is, the more likely it is to respond. So if somebody gets down to bone-on-bone, a lot of times I don't even try it, and that's when you start looking at surgical options. But if there's still some joint space left, then those patients can respond well to these injections.

Tom: That's the importance of getting in early and making correct diagnosis.

David: Right.

Tom: So with the corticosteroid injection, as well as the viscous injections, they last for a few months, and maybe longer in certain people. When can you repeat those, and how often can you repeat those injections if they work well?

David: Oh, that's a great question. With corticosteroids, kind of a general rule is I wouldn't do it more than about three times a year. With viscosupplements, insurance companies will cover that about every six months. So most people with viscosupplements, it lasts a little bit longer. And typically with a viscosupplement, it's usually a series of three injections. And with the first injection, we put a corticosteroid in with the viscosupplement. So you get kind of a quick onset of the corticosteroid and the longer lasting on set with the viscosupplement itself.

There's a couple other injections, too . . .

Tom: Yeah, let's talk about those.

David: . . . that can be done. One is called PRP, or platelet-rich plasma. And platelets have certain growth properties, healing properties, so we draw the patient's blood, spin it down, separate the platelets and inject that into the joint. And then I think a lot of people have probably heard about stem cells, and there's been a lot of publication about that. And I think if you think about it more as pain-relieving and maybe slowing down the progression of arthritis, rather than that it really heals or reconstitutes the joint, then stem cells can also be a good treatment for the joints.

Tom: Let's talk about the stem cell therapy for just a little bit. Now, is that obtained from the patient's own blood? And then, how do you do that?

David: There's different ways to obtain it. One is through bone marrow, so we do a bone marrow aspirate, usually out of the pelvis, which is a relatively pain-free procedure. Another way is derived from peripheral fat, so we can take fat cells and obtain the stem cells. And the third way, and this a little bit more controversial, but there's more and more amniotic stem cells that are out there. But there are some question about how many stem cells there really are, depending on how they're stored. A lot of times those are stored freeze-dried, and it's a little bit questionable on whether there's significant stem cells in that, or not. But there's no question that some of these amniotic stem cell treatments have helped patients, myself included, with arthritic pain.

Tom: That's great. You've listed a whole list of procedures and treatments that can perhaps delay and improve patients' function and decrease pain prior to considering a total joint replacement. I think the first thing you said is, one, be healthy, lose weight, and then keep fit, use a physical therapist to strengthen the ligaments and tendons, muscles around the joint. And then moving on from there, to seek a diagnosis early on so that certain therapies can be applied before things get to be too advanced, and then, you know, eventually you just have to move into a joint replacement.

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Dr. Miller: Who gets ankle arthritis and what to do about it. We're going to talk about that next on scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Alexej Barg. Alexej is a professor of orthopedic surgery here at the University of Utah. Alexej, who gets ankle arthritis?

Dr. Barg: This is a very particular problem. We don't know actually why that people do develop, for example, knee osteoarthritis or hip osteoarthritis, however, we know exactly who does develop the osteoarthritis of the ankle joint or the subtibiotalar joint.

Dr. Miller: That's really interesting. I mean, we are more commonly used to hearing about knee and hip arthritis, not so much about ankle arthritis.

Dr. Barg: The most common reason to develop ankle osteoarthritis is previous trauma. It can be the bony fracture, but it can be also the repetitive ligament sprain of the ankle joint.

Dr. Miller: Due to sports injuries typically? Or is this some line of work that would be a problem?

Dr. Barg: Both injuries can lead or can end up final in end-stage ankle osteoarthritis. And many people do speak about hip or knee osteoarthritis however the ankle osteoarthritis is a growing problem. Upcoming in Europe and in Europe right now every tenth patient who is coming to an outpatient clinic for an orthopedic problem is coming with a problem of ankle or the foot, including ankle osteoarthritis. So this is a growing problem. It should not be underestimated. There are some studies showing that the patient having end-stage ankle osteoarthritis have the same pain, the same disability in daily activities comparable to those patients having, for example, hip osteoarthritis.

Dr. Miller: So it's obviously painful. So again, what is it that causes this arthritis? What sorts of people are prone to develop ankle arthritis?

Dr. Barg: In the past decades, several studies have been published to figure out which are the risk factors to develop ankle osteoarthritis, especially posttraumatic ankle osteoarthritis. And I would say in my opinion there are two very important factors: the first is definitely the severity of the initial injury. For example, if you have a fracture of the lower leg including the tibiatalor joint surface, that means that those patients have also the cartilage lesion at the time of the initial injury. And the second significant risk factor is for sure the deformity because some people or the most people, more than the half of all patients with ankle osteoarthritis, have a concomitant lower leg deformity. That means they have uneven load distribution within the joint, which finally leads to end-stage disease.

Dr. Miller: So it sounds like fracture of the foot, fracture of the ankle can lead to ankle arthritis. Is that correct?

Dr. Barg: This is correct. This is absolutely correct. And . . .

Dr. Miller: So automotive accidents, industrial accidents can lead to arthritis.

Dr. Barg: Yes, absolutely correct. However, the bony fractures of course they are severe injuries and everybody is aware of it. However, I mentioned this before, also there are repetitive ankle sprains and ankle sprains are definitely the most common sports injury in this country but also worldwide. I would say if you have at least two or three ankle sprain a year that means you are at high risk to develop, sooner or later, ankle osteoarthritis.

Dr. Miller: And so does ankle arthritis develop at a younger age typically than we see hip and knee arthritis in the United States? I think in general we will see knee and hip arthritis at the age of 55 and above.

Dr. Barg: This is another challenging problem specifically in this patient group. You mention this correctly. The patient with knee or hip osteoarthritis, they are usually in their fifth or sixth life decade. Patients with end-stage ankle arthritis, they are much younger. So sometimes I even see patients that are 30, 35 years old and their ankle joint is really gone. That makes the treatment is this patient group specifically very challenging because whatever you plan to do in those patients they should usually last for many years. That means for another 50 or maybe even 60 years in the future.

Dr. Miller: Typically patients with ankle arthritis will present with pain and, I suppose, immobility, some type of immobility in the ankle. So what then are the next steps? Obviously they make their way to you, they know about your practice. What do you advise them?

Dr. Barg: First of all, I take a very exact medical history. So I want to know exactly how long the patient had the pain. What type of injury, if they had an injury, what type of injury exactly they had? Usually, I collect all possible medical records from the past. And the second step is definitely the clinical assessment, the clinical investigation. I do see how good the movement of the ankle is. I want to also check the alignment. That means they ask whether the ankle joint is straight or not. I also check the stability. And then finally I go further with the imaging, which is an extremely important part.

Dr. Miller: X-rays, typically?

Dr. Barg: Yeah, I always stay with a weight-bearing radiograph. Weight-bearing if very important. Many patients come from the family doctors, for example, with some imaging, but this imaging is not useful. I call is accidental imaging. Because you see just a very small part of the ankle, not weight bearing. That means you still see some ankle osteoarthritis, however, because they are not weight-bearing radiographs, you cannot really assess for example the alignment of the ankle joint.

Dr. Miller: So you're going to do a more thorough radiographic examination based on weight-bearing than typically you would see in a standard practice. Okay.

Dr. Barg: Yes.

Dr. Miller: Then, moving on to treatment, there are obviously different types. You can fuse the ankle, but there are other aspects of that care as well, I gather.

Dr. Barg: In the literature, mostly two treatments are described for the end-stage ankle osteoarthritis. This is to fuse the ankle or to replace the ankle. That means to use an ankle prosthesis. An ankle prosthesis, especially in the last two decades, experienced a really great progress. Regarding the design of prosthesis, they are definitely some designs are more anatomical design, which may really mimic much better the normal anatomy and normal biomechanics of the ankle joint.

However, in my opinion, both treatment options are not perfect. And so, therefore, in my clinic, we always try to use the joint preserving procedure. That means a surgery where you try to correct the underlying deformity. And you don't have to fuse the ankle. You don't have to replace the ankle. That means the patient still has their own ankle.

Dr. Miller: For our listeners, fusing the ankle, what does that mean?

Dr. Barg: To fuse the ankles means that you can do it actually laparoscopically, that means minimally invasive. Or you can do an open procedure. You just remove the remaining cartilage, you stabilize the tibiatalar joint using different implements. It can be screws, it can be plates.

Dr. Miller: These are the large joints at the back of the ankle, I guess.

Dr. Barg: Yes. And this for many decades has been the gold standard procedure for end-stage ankle osteoarthritis. The problem is for those patients the ankle joint does not move. That means that the functionality of the ankle joint should be taken over by adjacent joints. For example, by the subtalar joint, which is the joint underneath. And that means sooner or later those patients will develop diminutive changes in their adjacent joints. That's the biggest problem following ankle fusion.

Dr. Miller: Similar problem to folks who have disc fusions in their back.

Dr. Barg: This is maybe a similar problem, yes. Absolutely.

Dr. Miller: Some of them develop arthritis above and below the fusion.

Dr. Barg: I agree with you.

Dr. Miller: So because the points of stress change.

Dr. Barg: I agree with you.

Dr. Miller: Interesting. Alexej, in your experience, rebuilding the ankle joint, how durable is that? How long-lasting is that surgery? How much relief will it give and how long can one expect that to be helpful?

Dr. Barg: These questions cannot be answered clearly with a certain number, like two years, five years, 10 years. In my experience, if you do the joint preserving procedure, approximately 20% of all patients still need a bigger surgery like ankle fusion or ankle replacement within 10 years after the surgery. Which maybe the first sign is not that encouraging number, however, I can just tell you that if you do a very exact selection for this procedure, the patients are very happy because they still have their own joint. They don't have any restrictions doing, for example, recreation or sports activity. And actually this number is very dependent on how severe the ankle osteoarthritis is. I do communicate this very often and very clearly with the patient and I tell him what his expectation should be in the particular case.

Dr. Miller: It sounds like you have a great knowledge of the prognosis of each of these procedures that would help your patients make a decision on what to do.

Dr. Barg: Yeah, most likely we can say and predict exactly whether the procedure will last for two years or five years or for the 10 years. And for two years, sometimes if the patient is, for example, a hard worker and has to work on the street and has to lift heavy weight, this patient will not profit immediately, for example, for ankle fusion or ankle replacement. He'll want to wait another two or five years until he's retired and then he's ready for another surgery. Those patients are very thankful that you can offer them the joint preserving procedure.

Dr. Miller: Are there other tips for people who might have ankle arthritis? How do they find their way to a particular orthopedic surgeon? Should they see a specialist? Should they see a generalist orthopedic surgeon or should they see someone else, like a sports medicine physician?

Dr. Barg: I would suggest if the patient has ankle osteoarthritis, it doesn't mean a late stage. If it's at the early stage or the end-stage, this is a very challenging problem with many concomitant problems, which can be overseen by a person who is not that experienced in this area. By concomitant problems, I'm speaking, for example, about a concomitant deformity, a concomitant instability and so forth. So I do really think that those patients should really be seen be a person who has experience in dealing with this problem and who can also offer a different treatment option. Because the treatment options in the beginning of ankle osteoarthritis are definitely different, for example, than for patients with end-stage ankle osteoarthritis.

Dr. Miller: So bottom line is if you have ankle pain, try to have that diagnosed earlier rather than later. And if you have ankle arthritis, find your way to an orthopedic specialist who specializes in lower extremity problems.

Dr. Barg: Yes, absolutely. I agree with you.

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