Presentation on theme: "Running Healthy: Protecting, Preserving and Restoring Cartilage"— Presentation transcript:
1Running Healthy: Protecting, Preserving and Restoring Cartilage Matthew Busam, MDCincinnati SportsMedicineTeam Physician: Elder HS
2“If you have a body, you’re an athlete.” -Bill Bowerman
3Goals Review evidence concerning running and arthritis Review supplementsReview “cortisone” injectionsReview signs and symptoms of when we ask our patients to stop running and consider further evaluationSurgical advances in articular cartilage injuries
4Benefits of running Physical Psychological Cardiovascular Weight managementIntellectual? – regular exercise can improve cognition (at least in mice)Maintenance of bone mineral densityProtective effect for joints?Psychological
5Adverse effects Injuries 30% of “serious distance runners” >25 miles per weekwill be injured in a given year30% of these injuries involve the knee
6Running & ArthritisDoes running cause arthritis?NO!
7But what about…?Anecdotal evidence for just about anything. No proven relationship implicating running with development or progression of osteoarthritis
8ExamplesJAMA Mar 7;255(9):Lane NE, Bloch DA, Jones HH, Marshall WH Jr, Wood PD, Fries JFLong-distance running, bone density, and osteoarthritis.Running is associated with increased bone mineral but not, in this cross-sectional study, with clinical osteoarthritis
9EvidenceJ 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
10Curr 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.
12Arthritis 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.
13Long-term study:Percent Pain Increase Age Female Runners:11.8% Female Control: 70.6% Male Runners: 17.6% Male Control: 41.4%
15Objective Findings Am J Sports Med. 2004 Jan-Feb;32(1):55-9. Hohmann E, Wörtler K, Imhoff ABMR imaging of the hip and knee before and after marathonResults 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
16Objective FindingsAm 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
17Objective findingsSkeletal Radiol Jul;37(7): Epub 2008 May 16. Krampla WW, Newrkla SP, Kroener AH, Hruby WFChanges on magnetic resonance tomography in the knee joints of marathon runners: a 10-year longitudinal studyLoads 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.
18Causes of knee pain in runners Anterior knee painLateral pressure syndromePatella instabilityExtensor mechanism tendinopathyOthersMeniscusFocal chondral defectsOABursitisStress fractureITBPopliteal tenosynovitisLigamentous instability
19Treatment: Where to intervene Training programsAnatomy, biomechanicsShoes, orthoticsMuscles: weakness, imbalancePhysical therapyMedicationSurgeryRehab
20Where to Start?The best way to protect the knees of runners is with regular stretching and strengthening exercises…in addition to running!
21Quads and Hamstrings Patellofemoral pain Anterior knee pain “Runners Knee”
22Runners are tough, but weak! Running does not produce strengthIt produces enduranceWeakness leads to imbalance pain and injury
27ShoesAm 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.
28Shoes Midsoles wear out before outsoles If outsole is worn, midsole is likely worse!Mileage estimates are really just guesses, but usually300 miles is time for new footwearUnless pt is a very efficient, lightweight runner
29Running through Injury Yes, No, and MaybeYes for shin splintsNo for stress fracturesNo when swelling is present
33Supplements“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!”
34What 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 categoryAsterisk 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.”
35Glucosamine“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-analysisFlorent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, MSc; Michel Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; Jean-Yves Reginster, MD, PhDArch Intern Med. 2003;163:
36Glucosamine & 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.
37GlucosamineAnother 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):
38Glucosamine: 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
39ChondroitinStudy 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
40ChondroitinPrimary 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.
41MSM 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
42Omega-3 Shark Cartilage Little clinical evidence exists to support assertions that omega-3s are effective against arthritis.Shark CartilageNo 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
43Supplements OverallOf 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 productsIf 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)
44InjectionsClinical 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.
45Injections (My philosophy) As an anti-inflammatoryWhen pt has effusionWhen OA is knownNot given to “return to sport”As an adjunct to PTDecrease acute symptoms to allow proper participation in physical therapyNot more than 3 per year.
50Microfracture 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 defectDifferentiate into fibroblasts which produce a fibrocartilage “healing” of the defect
51Microfracture Correct and incorrect methods Correct: Debride defect, leaving a sharp shouldered edge.
76Return to sports? MFX, ACI, OATS, OCA: Durable enough to allow long-term cutting, pivoting, impact sports?Studies are limitedIf these heal and incorporate, can attempt return to play if symptom freeWould not typically advise return to distance running.For ACI, sports participation meant better long-term results.
77DurabilityMAT 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.
78The Future Resorbable matrix scaffolds Off-label in US if used for focal defectsGood results have been reported at short-term f/u