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

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Presentation on theme: "Running Healthy: Protecting, Preserving and Restoring Cartilage Matthew Busam, MD Cincinnati SportsMedicine Team Physician: Elder HS."— Presentation transcript:

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

2 If you have a body, youre 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 –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 NELane NE, Bloch DA, Jones HH, Marshall WH Jr, Wood PD, Fries JF Bloch DAJones HHMarshall WH JrWood PDFries JF Lane NEBloch DAJones HHMarshall WH JrWood PDFries 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): –Lane NE, Michel B, Bjorkengren A, Oehlert J, Shi H, Bloch DA, Fries JF. Lane NEMichel BBjorkengren AOehlert JShi HBloch DA Fries JFLane NEMichel BBjorkengren AOehlert JShi HBloch 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 Sep;11(5): Exercise and osteoarthritis. Lane NELane NE, Buckwalter JA. Buckwalter JA Lane NEBuckwalter 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):R Epub 2005 Sep 19. –Bruce B, Fries JF, Lubeck DP. Bruce BFries JFLubeck DPBruce BFries JFLubeck 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 Jan-Feb;32(1):55-9. Hohmann EHohmann E, Wörtler K, Imhoff AB Wörtler KImhoff AB Hohmann EWörtler KImhoff 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 CSchueller-Weidekamm C, Schueller G, Uffmann M, Bader TR. Schueller GUffmann MBader TR Schueller-Weidekamm CSchueller GUffmann MBader 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. Am J Sports Med May;36(5): Epub 2008 Feb 20. Kessler MAKessler MA, Glaser C, Tittel S, Reiser M, Imhoff AB. Glaser CTittel SReiser MImhoff AB Kessler MAGlaser CTittel SReiser MImhoff 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 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 Krampla WWNewrkla SPKroener AHHruby WF Krampla WWNewrkla SPKroener AHHruby 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 MedicationSurgeryRehab

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. Butler RJ Davis ISHamill JButler RJ Davis ISHamill 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…. Its like oil for your jointsit 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). 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. study 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 of 279 patients found no significant difference between chondroitin and placebo as far as the studys primary efficacy criteria (pain on daily activities and Lequesnes index) were concerned A recent 24-week trial of 279 patients found no significant difference between chondroitin and placebo as far as the studys primary efficacy criteria (pain on daily activities and Lequesnes index) were concernedtrial

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 bloods 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 supplements efficacy for osteoarthritis. –Evidence for this is spotty at best

42 Omega-3 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? –Dont make an asymptomatic finding a symptomatic problem –Dont be surprised! –Treatment and rehab is very different

48 Chondral repair

49 Options ObservationChondroplastyMicrofracture 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: –66% G-E results 44% returned to sports –57% of those at same level Steadman: % 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


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? DiseaseMismatchNon-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 –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 Dont be the last or first to do something! Thanks


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