You make $22 million per year, have access to the world's best medical care, have had three knee surgeries in three months time, but have not recovered. Your knee hurts, swells and your muscles are weak. This is Barry Bonds, the superstar slugger for the San Francisco Giants and many people have a lot of questions about why Bonds is not playing baseball.
What we know is the type and nature of his surgeries: arthroscopy for "minor arthritis cleanup and small meniscus tear"* on January 31, 2005. A second surgery followed on March 17, 2005 for "debridement of tears in the medial and lateral menisci of his right knee". Finally, a third arthroscopy on May 2, 2005 for a bacterial infection. Bonds also had his fluid removed from his knee three times since the March 17th surgery.
What we don't know is the type of rehabilitation Bonds had. This is crucial. Why? Because surgery does not "fix" the problem. A "minor arthritis cleanup" removes frayed and damaged cartilage from the joint. But, surgery does not improve the joint surface. The cartilage is no healthier after surgery than before. Soft, weak, diseased cartilage needs more than surgery. Cartilage needs controlled motion and load.
Cartilage is a biologic tissue that is exceptionally sensitive to physical load. In fact, it is physical load that causes cartilage to either produce new cells or destroy existing cells. Immediately following a "minor arthritis cleanup", the joint surface needs nourishment. Cartilage has no blood supply and the only way it receives vital nutrients is from movement. Cartilage gets its "food" from gentle, repeated motion with a gradual increase in the physical force. When your knee moves, as in gently riding a bicycle, the synovial fluid bathes the joint surface. From this bathing action, the cartilage begins to form new cells and to rebuild its framework. The framework holds or binds water making it resistant to compression. A little compression, a little motion and cartilage cells go to work. Too much compression and too much motion, cells are sheared away, float through the joint, cause swelling and a gradual softening of the joint surface.
When you have your knee drained, in most cases, you can assume your cartilage is not healing. And, this extra fluid causes arthrogenic inhibition of the quadriceps muscle or in other words the excess fluid shuts down the muscles ability to contract. As long as you have excess fluid in the knee, which by the way is only a few cubic centimeters, your quadriceps will not work very well. You can try all the things you want; use electrical stimulation; rub it; stretch it; ice it; put heavy weights on the leg. It will not work. It's like a light bulb on a dimmer switch, it is barely glowing and no matter how hard you try to turn the switch up, it's just dim.
When the rehab pace is too fast, your knee will tell you. It will swell or ache. Your muscles will not work very well. Your knee may feel "full". You may not be able to fully bend or straighten it. The most common clinical mistake is designing a rehab program focused around regaining muscle strength without also restoring the joint surface strength. Barry Bonds' problem is fundamentally a cartilage problem. His rehab should be organized around an understanding of what cartilage needs to rebuild its strength. But, here's what usually happens. The rehab program is based on the idea that by strengthening the muscles you can protect the joint. A bit like an extra shock absorber. Sounds great and it is true. Strong muscles will help protect your joints. However, the forces required to fatigue the muscles in order to strengthen them exceed the joint surface strength and, as a result, your knee hurts or swells. So, you have to slow down, lower the resistances or loads. But, these loads do not fatigue your muscle and with no muscle fatigue, there will be no strength gain. Thus, you once again increase the loads only to find yourself right back in the same place: swelling, aching and pain. Over and over and over.
A "minor arthritis cleanup" is not minor. Maybe if you did not need a general anesthetic or spinal epidural, then I might call it minor. A hangnail is minor. A small scratch is minor. Stubbing your toe is minor. Surgery, no matter the type, is not minor. And, the rehab following surgery is not minor either.
Will Barry Bonds play baseball again? I hope so. He's fun to watch and looks like he enjoys what he does. But, if he hopes to play, he had better hope his rehab is on the money. For that matter, so should the Giants or they may be out of a lot of money; like $22 million.
Author. Speaker. Therapist.
*Source: Denver News Channel 7