1. Running Healthy: Protecting, Preserving and Restoring Cartilage
Matthew Busam, MD
Cincinnati SportsMedicine
Team Physician: Elder HS

2. “If you have a body, you’re an athlete.” -Bill Bowerman

3. Goals Review evidence concerning running and arthritis
Review supplements
Review “cortisone” injections
Review signs and symptoms of when we ask our patients to stop running and consider further evaluation
Surgical advances in articular cartilage injuries

4. Benefits of running Physical Psychological Cardiovascular
Weight management
Intellectual? – regular exercise can improve cognition (at least in mice)
Maintenance of bone mineral density
Protective effect for joints?
Psychological

5. Adverse effects Injuries 30% of “serious distance runners”
>25 miles per week
will be injured in a given year
30% of these injuries involve the knee

6. Running & Arthritis
Does running cause arthritis?
NO!

7. But what about…?
Anecdotal evidence for just about anything. No proven relationship implicating running with development or progression of osteoarthritis

8. Examples
JAMA Mar 7;255(9):
Lane NE, Bloch DA, Jones HH, Marshall WH Jr, Wood PD, Fries JF
Long-distance running, bone density, and osteoarthritis.
Running is associated with increased bone mineral but not, in this cross-sectional study, with clinical osteoarthritis

9. Evidence
J Rheumatol Mar;20(3):461-8.
Lane NE, Michel B, Bjorkengren A, Oehlert J, Shi H, Bloch DA, Fries JF.
The risk of osteoarthritis with running and aging: a 5-year longitudinal study.
Running did not accelerate the development of radiographic or clinical OA of the knees

10. Curr Opin Rheumatol. 1999 Sep;11(5):413-6.
Exercise and osteoarthritis.
Lane NE, Buckwalter JA.
Recreational jogging in individuals 60 or more years of age with normal knee and hip joints does not increase the risk for the development of osteoarthritis.

11. Who hurts more?

12. Arthritis Res Ther. 2005;7(6):R1263-70. Epub 2005 Sep 19.
Bruce B, Fries JF, Lubeck DP.
Aerobic exercise and its impact on musculoskeletal pain in older adults: a 14 year prospective, longitudinal study.
Compared runners, who averaged about 26 miles a week, to a matched set of controls, who averaged about two miles a week. "If running creates damage through accumulated trauma, then runners with about ten-fold the exposure to such trauma should have increased pain over time." The runners experienced "about 25 percent less musculoskeletal pain" than the controls.

13. Long-term study:
Percent Pain Increase Age Female Runners:11.8% Female Control: 70.6% Male Runners: 17.6% Male Control: 41.4%

14. Imaging Data

15. Objective Findings Am J Sports Med. 2004 Jan-Feb;32(1):55-9.
Hohmann E, Wörtler K, Imhoff AB
MR imaging of the hip and knee before and after marathon
Results suggest that the high impact forces in long-distance running are well tolerated and subsequently do not demonstrate changes on MR images.
Eur Radiol Oct;16(10): Epub 2006 Mar 10.
Schueller-Weidekamm C, Schueller G, Uffmann M, Bader TR.
Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging.
The evaluation of lesions of the knee with MRI shows that marathon running does not cause severe, acute lesions of cartilage, ligaments, or bone marrow of the knee in well-trained runners

16. Objective Findings
Am J Sports Med May;36(5): Epub 2008 Feb 20.
Kessler MA, Glaser C, Tittel S, Reiser M, Imhoff AB.
Recovery of the menisci and articular cartilage of runners after cessation of exercise: additional aspects of in vivo investigation based on 3-dimensional magnetic resonance imaging.
Recovery period of 1 hour, articular structures returned to normal

17. Objective findings
Skeletal Radiol Jul;37(7): Epub 2008 May 16. Krampla WW, Newrkla SP, Kroener AH, Hruby WF
Changes on magnetic resonance tomography in the knee joints of marathon runners: a 10-year longitudinal study
Loads experienced in marathon running do not cause permanent damage in the internal structures of the knee. A disposition for premature arthrosis was not registered in the population investigated.

18. Causes of knee pain in runners
Anterior knee pain
Lateral pressure syndrome
Patella instability
Extensor mechanism tendinopathy
Others
Meniscus
Focal chondral defects OA
Bursitis
Stress fracture
ITB
Popliteal tenosynovitis
Ligamentous instability

19. Treatment: Where to intervene
Training programs
Anatomy, biomechanics
Shoes, orthotics
Muscles: weakness, imbalance
Physical therapy
Medication
Surgery
Rehab

20. Where to Start?
The best way to protect the knees of runners is with regular stretching and strengthening exercises…in addition to running!

21. Quads and Hamstrings Patellofemoral pain Anterior knee pain
“Runners Knee”

22. Runners are tough, but weak!
Running does not produce strength
It produces endurance
Weakness leads to imbalance pain and injury

23. Closed chain quad rehab

24. Iliotibial Band Streching/Strengthening

25. Stretching

26. Strengthen

27. Shoes
Am J Sports Med Dec;34(12): Butler RJ, Davis IS, Hamill J.
Interaction of arch type and footwear on running mechanics.
Running footwear recommendations should be based on an individual's running mechanics. If not available, footwear recommendations can be based arch type.

28. Shoes Midsoles wear out before outsoles
If outsole is worn, midsole is likely worse!
Mileage estimates are really just guesses, but usually
300 miles is time for new footwear
Unless pt is a very efficient, lightweight runner

29. Running through Injury
Yes, No, and Maybe
Yes for shin splints
No for stress fractures
No when swelling is present

30. Return from Injury

31. Graduated return to sport program
Prolonged process
Start slow
Gradually increase time and distance
Then focus on speed

32. What about regrowing cartilage?

33. Supplements
“Patented ingredients help support, ease, and rebuild joints….”
“Soothe away joint pain and watch as your skin regains a nourished, youthful appearance….”
“It’s like oil for your joints—it helps promote full range of motion and flexibility.”
“New Miracle Relief Formula eliminates even the worst pain...almost instantly!”

34. What is a Supplement? U.S. Food and Drug Administration (FDA)
dietary supplements: subcategory of “food,” providing manufacturers with greater leeway and less oversight than products in the pharmaceutical category
Asterisk syndrome: product is advertised to promote and maintain “joint strength,* joint flexibility,* joint lubrication,* range of motion,* production of lubricating fluid,* and renewal of cartilage and connective tissue.*” “*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

35. Glucosamine
“highly significant efficacy” for all outcomes, including joint space narrowing and Western Ontario MacMaster University Osteoarthritis Index (WOMAC).
Structural and Symptomatic Efficacy of Glucosamine and Chondroitin in Knee Osteoarthritis A Comprehensive Meta-analysis
Florent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, MSc; Michel Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; Jean-Yves Reginster, MD, PhD
Arch Intern Med. 2003;163:

36. Glucosamine & Chondroitin
GA stimulates production of collagen and its precursors. It may also have an antiinflammatory role.
CS inhibits enzymes that break down cartilage. It also adds to the pool of molecules that form collagen.
The combination of these compounds is considered to enhance cartilage protection.

37. Glucosamine
Another study reported on 1,583 patients with symptomatic knee osteoarthritis who were randomly assigned to take glucosamine, chondroitin, a combination of glucosamine and chondroitin, celecoxib, or placebo over 24 weeks. Overall rate of response to glucosamine, chondroitin, and the combination were not found to be significantly better than placebo, although patients with moderate to severe pain at baseline were observed to respond significantly better with the combination.
N Engl J Med Feb 23;354(8):

38. Glucosamine: Side effects
Primary side effects:
mild gastrointestinal complaints such as constipation, diarrhea, cramping, gas, heartburn, and nausea. Glucosamine sulfate has been associated with drowsiness and headache. The effects of glucosamine on nursing or pregnant women have not been well-studied.
Glucosamine may increase blood sugar levels. Although studies of glucosamine on patients with diabetes are inconclusive, it is believed that higher doses may prompt the pancreas to produce less insulin, so caution is advised.
Because glucosamine is often made from shellfish and the source of the product is not required to be on the label, individuals who are allergic to seafood are advised to exercise caution as well

39. Chondroitin
Study participants have generally reported a decrease in pain and increases in joint movement when taking chondroitin, although it is not uncommon for participants to take chondroitin in combination with aspirin or other conventional arthritis treatments, so the true extent of the efficacy of chondroitin remain unclear.
Some studies seem to show that chondroitin must be taken for up to 4 months before benefits are realized.
A recent 24-week trial of 279 patients found no significant difference between chondroitin and placebo as far as the study’s primary efficacy criteria (pain on daily activities and Lequesne’s index) were concerned

40. Chondroitin
Primary side effects:
uncommon and include hair loss and minor gastrointestinal complaints. The effects of chondroitin on nursing or pregnant women have not been well-studied.
Chondroitin can decrease the blood’s ability to clot, and it is not advisable to take it concurrently with aspirin, antiplatelet, or anticoagulant drugs.
Chondroitin products are also sometimes combined with manganese, which may assist in cartilage production, but is toxic in large doses. The U.S. National Academy of Sciences has set the adult tolerable upper limit for manganese at 11 mg/day; patients should be advised not to exceed that level.

41. MSM Methylsulfonylmethane (MSM)
Treatment for a variety of conditions from osteoarthritis to stress and snoring.
Few clinical trials examine the supplement’s efficacy for osteoarthritis.
Evidence for this is spotty at best

42. Omega-3 Shark Cartilage
Little clinical evidence exists to support assertions that omega-3s are effective against arthritis.
Shark Cartilage
No proof that taking a shark cartilage supplement provides benefits.
No studies have been conducted to determine whether shark cartilage has any serious or long-term side effects

43. Supplements Overall
Of the commonly available supplements, glucosamine, chondroitin, or a combination of the two appear to have the greatest efficacy based on clinical trials, but a number of researchers remain guarded even when recommending those products
If less than 120 lbs: GA 1000mg + CS 800mg (1 tab twice a day)
Between : GA 1500mg + CS 1200mg (2 tabs in morning and 1 tab in afternoon)
If greater than 200: GA 2000mg + CS 1600mg (2 tabs twice a day)

44. Injections
Clinical data supports the uses of intra-articular corticosteroids, even in repeated use (up to every 3 months for up to 2 years) particularly for patients with knee OA.

45. Injections (My philosophy)
As an anti-inflammatory
When pt has effusion
When OA is known
Not given to “return to sport”
As an adjunct to PT
Decrease acute symptoms to allow proper participation in physical therapy
Not more than 3 per year.

46. Focal Chondral Defects
OCD
Osteochondritis dissicens
Osteochondral defect

47. FCD: Treatment Is it symptomatic?
Don’t make an asymptomatic finding a symptomatic problem
Don’t be surprised!
Treatment and rehab is very different

48. Chondral repair

49. Options Observation Chondroplasty Microfracture OATS (AOT)
ACI (Carticel)
Osteochondral allograft
Meniscus transplants
Ligament reconstruction
Correction of alignment
Osteotomy

50. Microfracture Marrow stimulation technique
Body will produce repair tissue for a chondral defect if undifferentiated mesenchymal cells are accessed.
Marrow cells, blood, platelets organize into the defect
Differentiate into fibroblasts which produce a fibrocartilage “healing” of the defect

51. Microfracture Correct and incorrect methods Correct:
Debride defect, leaving a sharp shouldered edge.

53. Microfracture

54. Microfracture is not “poking some holes in the cartilage”
“the same rehab as a menisectomy”

55. Rehab TTWB for 6-8 weeks (modified based on lesion location)
CPM at home for 6-8 weeks
After 6-8 weeks begin active ROM and progress to full WB
Cutting, twisting, pivoting 6 months

56. Success and cautions
Return to impact sports
Maybe not

57. Data HSS: 2006. Steadman: 2003 66% G-E results 44% returned to sports
57% of those at same level
Steadman: 2003
76% of NFL players returned to play next season

58. Steadman: 2003
11.3 year f/u
Pts 45 and younger with no meniscal or ligamentous pathology
Showed improvement in function and had less pain.

59. Contraindications Malalignment Ligamentous instability
Unshouldered lesions
Lesions > 10 mm deep
Tibial lesions – less predictable results

60. ACI Autologous chondrocyte implantation 2 stage procedure
Scope, biopsy
Culture cells
Reimplant cells under patch
(periosteum)

61. Pre-implant

62. Post implant

63. Rehab Protected WB CPM No running or impact loading until 12 months
High level sports at 16 months if pain free

64. Hypertrophy
Reported with need for reoperation in up to 36% of patients…
Reduced with non-periosteal covers
collagen

65. After delamination

66. ACI as a second line Rx
Unfortunately marrow stimulation techniques increase failure rate from ACI by up to 3X!
Might not be best to mx then plan ACI if no better

67. OATS/ AOT

68. Osteochondral autograft transfer
Moves cartilage and its supporting bone
Successful provided defect is not too large
Limited by size
Supply of cartilage

69. OCA
Transplantation of allograft (cadaveric) cartilage and supporting bone.
Successful in many series
Concerns
Disease
Mismatch
Non-healing

70. Osteochdral allograft

71. Technique

72. Final

73. Allograft meniscus transplantation
Role of intact meniscus is unquestioned
Does an allograft function like a native meniscus?
Disease
Mismatch
Non-healing
Is it simply an “interposition arthroplasty”?

74. Meniscus Transplant

76. Return to sports? MFX, ACI, OATS, OCA:
Durable enough to allow long-term cutting, pivoting, impact sports?
Studies are limited
If these heal and incorporate, can attempt return to play if symptom free
Would not typically advise return to distance running.
For ACI, sports participation meant better long-term results.

77. Durability
MAT and OCA have not been shown to have long-term superiority to prosthetic replacements.
These are often “bridge” procedures that allow younger patients to avoid metallic arthroplasty and thus avoid revision.

78. The Future Resorbable matrix scaffolds
Off-label in US if used for focal defects
Good results have been reported at short-term f/u

79. The Future MACI Cartilage “slurry” Equine cartilage
Matrix-induced ACI
Culture chondrocytes implanted in collogen matrix prior to implantation
No periosteal flap needed
Cartilage “slurry”
Equine cartilage
Genetic alterations

80. The Future
Don’t be the last or first to do something!
Thanks