The View from Sports Center

Tiger - a Verb? (READ THIS ONE)

"Hey, buddy - you might want to think about that first. You don't want to tiger your knee, do you?"

Tiger played for a year on an injured, unstable knee; a knee that with each powerful swing, chipped away at the protective lining of his joint - the articular cartilage. And a lot of people are left scratching their heads wondering, "Why?"

Maybe it's because no one sat down with him and had "the talk": eye to eye, close up, intense, in-your-face honesty about what was coming if he chose to play without reconstructing his knee. Or, maybe someone had the talk but Tiger chose not to listen. We don't know but I suspect it was a blend of both.

I understand the power of emotion behind the drive to prove your self, to be the best, to never let up. Those are the character traits of winners. And, ironically, they are the same traits that can put you on the sidelines for a very long time when faced with an injury like Tiger's.

I would hate to see Tiger's choice to play on an injured knee, to play wrapped in denial, become a verb in everyday life; to become a word that describes a misguided personal choice rather than a word the describes a masterful golfing choice. He can make a come back but only if he can channel his competitiveness into behaviors that help him rather than hurt him.

Make today count.
Doug Kelsey

P.S. - so I goofed on my last post. I had started it and saved it and sent it without it being completed. Sorry you got this one twice.

Tiger is Out

Tiger is out for the rest of this season.

According to his web site, he will undergo reconstructive surgery for a torn anterior cruciate ligament and then go through rehab for it as well as a double stress fracture of the tibia. The stress fractures were discovered just before the Memorial tournament last month. "The stress fractures were attributed to Woods' intense rehabilitation and preparations for the 2008 U.S. Open." The arthroscopic surgery he had roughly six weeks ago was for torn cartilage caused by the tearing of the anterior cruciate ligament in 2007 (while running near his home in Orlando).

I'll have more thoughts on this later......

Anyone care to comment? Click the comment link below if you do.

Tiger's Winning. Is His Knee Losing?

"I'm gonna' get outta' here and ice this thing."
- Tiger Woods at the post-round three news conference of of 2008 U.S. Open

With every swing, I cringe and cheer. Launching a powerful tee shot that nearly brings him to his knees, limping down that fairway using his driver as a cane, chipping in to hole a birdie..it's Hollywood at its best. Watching Tiger charge from behind to take the lead with a wounded knee is inspiring...until I snap back into reality.

I cringe because I fear that Tiger either doesn't know or chooses to ignore that a joint injury is simply not the same as a muscle injury. Commentators made comparisons to the great Willis Reed of the N.Y. Knicks who in 1970 shuffled onto the court dragging an injured right leg behind him to lift his team to victory over the Los Angeles Lakers. What they fail to mention is that Willis had a torn right thigh muscle and that just a little over a year later, his career was essentially over.

A joint injury is a more difficult injury than a muscle injury. Ice does little to help a joint injury and forging ahead despite the pain can create a life long battle that sometimes is career ending.

I'll watch the U.S. Open tomorrow and cringe and cheer for probably the best golfer ever. And hope that somehow, someway, his joint heals and we'll get to enjoy the Tiger of our time for a long, long time.

A Tiger in Trouble

"...it is what it is and you have to deal with it."

So says Tiger Woods after finishing five strokes back in round one of the 2008 U.S. Open.

For those of you who might not know, Tiger underwent arthroscopic knee surgery at the end of April of this year for persistent knee pain. What actually was done in the surgery is as mysterious as my golf swing. I'm guessing, based on his prior knee problems, that he had a cartilage injury - either the meniscus or an articular surface (the cartilage that lines the end of the thigh bone, under the knee cap, and on top of the shin bone) , or both -  and had the tissue debrided. You're probably saying, "What the heck is that?" Some people describe it as having the knee "cleaned out" or, "cleaned up". An injury to the cartilage creates fraying and small chunks of the tissue float through the synovial fluid in your knee. Your knee will hurt, ache, swell, and generally feel lousy. Debriding removes the offending flakes.

But, what I wonder is how will Tiger "deal with it"? IF he had a cartilage injury and surgery for it, how much healing has occurred in roughly six weeks? Not much. Surgery does not change the health of the cartilage. The joint is cleaner, fragments are gone, but the tissue is still weak. And, cartilage heals slowly because it has no blood and no nerve supply to organize the healing process. Tapping into the body's natural healing potential for this kind of injury requires a precision level of load and motion control. The cells only know what to do through the application of force, in other words, pressure. But, for the first few weeks, the new cells are still as fragile as the flaky crust of an apple pie. Too much force or pressure, and the new cells will be sheared off to float through the synovial fluid setting the knee up for persistent swelling, aching, pain and decline.

Tiger winced in pain more than once today. So, something's not right. Does Tiger really need to play the U.S. Open? Honestly? No. Does he need the money? I doubt it. But, Tiger is not immune to the sirens of success and may suffer from a bit of "hemotion" too.

I wouldn't be surprised to see Tiger withdraw and he should. The smart play here is to not do a "Tin Cup" and go for it. The smart play is to listen to your body, tap into it's healing potential, heal your body, and then go for it.

When Less is More

I may be in the minority about this, but the kind of exercise you need for something like knee pain depends on why you have knee pain.

The kind of treatment you receive for heart disease depends on the nature of the disease; the kind of treatment you receive for a loose shoulder joint depends on why the joint is loose. Seems logical to me to conclude that the kinds of treatments (exercises) you receive or do for knee pain would then depend on why your knee hurts.

Like I've said before, pain is not THE problem; it's A problem. So, just because the front of your knee hurts, doesn't always mean that making your muscles stronger will solve the pain. It might, if you're lucky, but the less fit your are, the longer you've had the pain, the less likely that something like the exercises below will help for the long term.

One of the main problems is gravity. Climbing stairs, squatting, kneeling, sometimes walking, or practically anything where you apply force to your leg often turns into a frustrating and painful experience. The force or load of the activity on the tissues of your knee is greater than those tissues can take. The result is that you hurt.

Ok, so you might be thinking, "Well, then if I make my muscles stronger, then I should be able to take the force of gravity; the force of going up a flight of stairs."

Well, here's why just trying to strengthen your muscles often fails to deliver significant functional change; like climbing stairs, squatting, jogging.

One of the main reasons people have knee pain is due to osteoarthritis of the knee. This is a condition that causes a weakening of the cartilage that lines the end of the femur (thigh bone) and tibia (shin bone). The cartilage is weak, thin, frail, and fails to provide sufficient protection for the bone. It's like having lousy shocks on your car.

Now, some people don't believe that you can actually strengthen your joint (cartilage) despite the evidence that you can. What we have suggested for many years, it'll be over 20 for me, is that joints respond best to a load that matches what the joint can tolerate. For joints with osteoarthritis, the concept is No Pain, Gain. So, if squatting down to sit in a chair hurts, it's not the squatting that's the problem. It's the load that your knee joints must carry during the squatting motion. If you weighed less, and I'm not suggesting the solution is weight loss, although sometimes that would be a really good idea, in almost every case, your knees won't hurt. Now, something else that's very cool about joints is that when you perform squats at a level of force that the joints can tolerate and are consistent with the exercise (we like to use a Total Gym for this), the joints respond; they adapt, become stronger, sturdier, and can tolerate more force. Strength training for joints is a different kind of exercise regimen than strength training for muscle. When you try to use a level of resistance that muscles need to get stronger, osteoarthritic joints hurt and don't adapt. Instead, joints want less load, more motion and what you'll get is less pain and more strength and function.

Don't buy it? Well, this idea of reducing load during exercise to reduce knee pain in people with knee osteoarthritis was recently studied in two groups of patients: one group exercised in water while the other exercised on land**.

Care to guess which group had more pain relief and better function?

For osteoarthritis, less load, more motion will usually translate into less pain and more function.

P.S. Guess who else needs to know this.

References:

* Lu, Tung-Wu LU, Chien, Hui-Lien, Chen, Hao-Ling. Joint Loading in the Lower Extremities during Elliptical Exercise. Medicine & Science in Sports & Exercise. 39(9):1651-1658, September 2007.

** Jamtvedt, Gro, Dahm, Kristin Thuve, Christie, Anne, Moe, Rikke H, Haavardsholm, Espen, Holm, Inger, Hagen, Kare B. Physical Therapy Interventions for Patients With Osteoarthritis of the Knee: An Overview of Systematic Reviews PHYS THER 2008 88: 123-136

Do Women with Chronic Knee Pain Get Left Out?

If you have knee pain that did not respond to conservative care (physical therapy, cortisone injections, medication) and happen to be a woman, you might not be getting the same treatment options as a man.

In a recent Canadian study, men were offered knee replacement surgery twice as often as women even though women tend to have more arthritis, worse symptoms, and more severe disability.

And, this isn't the only problem that women seem to have trouble getting the same treatment as men. Other studies have found women who have a heart attack are less likely than men to receive cholesterol-lowering drugs or to be admitted to an intensive-care unit. And, you can add cardiac catheterization (to remove blockage in arteries), kidney dialysis, and kidney transplants to the list as well.

But, in the Canadian study, few of the doctors were women. So, you might consider a second opinion from a female surgeon. In any case, ladies, speak up. Don't get left out.

When Going Backward Helps You Go Forward

You've given up jogging, are on a trial separation from the elliptical, and you're doing your best to fall in love with the stationary bike but the truth is your knee still hurts.

How is that possible? How could something as easy as cycling hurt your knee?

If you were climbing steep hills, popping out of the saddle, really pounding your legs, you would probably nod your head and say, "Yeah, ok, I get that. That makes sense." But, when you're at the gym, pedaling just hard enough to break a sweat, and before long you have a headache in your knee, well, that doesn't make sense. It just doesn't seem hard enough to make your leg hurt.

One part of the answer is something referred to as WATTS. When you pedal a bike, you perform work - you crank the pedal against some level of resistance over a period of time - and the energy output from all that cranking is known as WATTS. You can produce WATTS from either using a heavy resistance (which tends to slow down your cranking) or use a lighter resistance with a higher speed or cadence.

When you reach 120 WATTS, the force in your knee will be equal to about 1.8 times your body weight. So, if you weigh 140 lbs., the force in your knee will be 252 lbs.

No wonder your knee hurts.

Unless you pedal backwards.

Pedaling backward (and still producing 120 WATTS) reduces the force in your knee to about body weight (and to give you some perspective, walking can produce a force equal to 2.0 times your body weight). Less force means less chance of pain. So, if you notice that your knee is bugging you from cycling you have several options:

• Reduce your speed or cadence.
• Reduce the resistance on the bike and keep your speed roughly the same.
• Pedal backwards.
• Pedal backwards with a reduced speed.
• Pedal backwards with less resistance and keep your speed about the same.

As your knee gets stronger and healthier, you can increase the resistance or the speed. But, consider changing one variable at a time or you'll end up going backward....again.

Cheers.
Doug Kelsey

Can I Run a Marathon?

Hi Dr. Kelsey,  Thanks so much for helping me!  Would you help me problem solve with a patient I have?  He is 46 y/o, a career marathon runner with no history of knee problems.  He had a skiing accident and tore his right medial meniscus.  He recently had surgery to remove the torn piece (which was a "small piece") and was sent to me for treatment.  Now he has no pain with full weight bearing, full active and passive extension without pain, 120° flexion passive motion with stiffness and pain.  He has fluctuating stiffness from current overuse as he is walking and standing for his job without resting.

I hope I gave you enough info to help me with his and my question which is "Will I be able to run marathons again?"  My thought is he could with optimal rebuilding ...possibly within 9 months to a year.  Do you think this is reasonable or is a smaller meniscus inherently unable to tolerate the loads created during a marathon?

A side note is that he has stated he will be happy with recreational running  (6-9 miles 3 times per week) if that is what's best for his body.

I know you're terribly busy and I always appreciate any thoughts you have.

You're faithful friend and follower (ha! ha!),

Janna

Hi Janna -

Always great to hear from a former student and friend. I would be happy to help you answer the question, "Will I run again?" You can click here, to read a prior View on this topic.

To run again, you must have certain physical capabilities in place. One of those is passing a single leg squat load tolerance test. To pass the test, you need excellent form (no deviations of the hip or upper leg), good distribution of motion between the hip and knee (so, the hip should flex about 110 degrees and the knee roughly 70 degrees - the perfect ratio), and no symptoms for 30 repetitions.  I'll bet, based on your description of him (stiffness from walking and standing), that he will not pass a single leg squat load tolerance test. If I'm right, then you have to spend your time reaching that objective first.

Once he has passed the single leg squat load tolerance, you can begin unloaded jogging (and, as I recall you have a Newton - yes?). Start at 75-80% body weight loads for short intervals (1 minute of jogging followed by 2 minutes of walking). First run should be no more than about 15 minutes. Adjust the load levels such that he has no pain during the session and short term (24-48 hours) discomfort after the session. Gradually increase the interval time until you reach 15 minutes of running. Then, decrease the unloading amount and repeat the cycle until you get down to 10 lbs. of unloading. At that point, increase the duration of the cycle to 30 minutes and start the sequence over.

As you think about this, you probably will come to the conclusion that it will take a while to reach thirty minutes of running. And, it should. You are conditioning the tissue to withstand significant levels of force. Cartilage is nudged into health; not shoved. So, it's a tedious process but it works quite well if those involved can stick to the program.

As for the time frame, 6-9 months, yes, to begin training for marathon level running but I doubt that you can rebuild the force capacity in the limb and run a marathon in 6, 9, or 12 months. Of course, I always like to ask, "Why?" This is for another time perhaps, but the reasons or drivers behind the desire to run are as important to discover and work through as the "injury" itself.

Doug Kelsey

Knee Pain: One Reader's Struggle

This week, I'm answering a question from a reader. It's a subject we hear a lot about and is one of our more popular posts on knee pain. In fact, this question or something like it hits either our blog or my inbox just about every week. So, following the comment below, are my thoughts on how to overcome Patellfemoral Syndrome.

Doug - I'm grateful for your post.

I'm currently doing research into Patellofemoral Syndrome rehab, as I've been suffering with knee pain in my right leg after running, on and off for 3 or 4 years. I have seen a physio four times over the last couple of weeks, who diagnosed the issue as a maltracking patella, caused by a combination of overpronation and a weak VMO. I've been given a selection of exercises and 'treatments' to address the issue and reduce pain during exercise. These include:

1. Stretching of hamstrings, quads and calf muscles (all are very tight, hamstrings are particularly short).
2. Theraband balance exercises and quad strengthening exercises (straight leg raises, partial squats etc.) - all outside the pain zone.
3. Molded orthotics for running and every-day shoes.
4. Strapping/taping instructions for when I need/want to exercise with reduced discomfort.

Although I acknowledge your point on isolation of the VMO, are you making any alternative suggestions for therapy, or would your opinion be that the above treatments are suitable and sufficient. Many thanks for your help.

Jules

Jules,

The list of treatments is not uncommon nor would I consider any of them to be inappropriate. But, the list is incomplete. And, yes, I do have suggestions on how to improve the solution.

The main problem with Patellofemoral Syndrome (PFS) is that the physical demand of the activity is greater than your physical capability. When the physical demand is too high, symptoms appear. For example, if you pull your index finger back slowly until you feel some resistance, you will notice a sense of tightness or pulling in your finger but it probably will not hurt. But, if you increase the pressure (the demand), your finger will begin to hurt.

When your foot hits the ground, the force of your body weight travels back up the leg and through the knee. The lining on the ends of your bones, the articular cartilage, disperses some of that force but when the cartilage is too soft (as in the case of Patellafemoral Syndrome), more of the force travels into the bone and other structures (tendon, ligament, joint capsule). As the force accumulates and exceeds the tissue capability, for example while running, your knee may hurt.

The treatments you listed are common so, here's the list again along with my impression of the purpose and the pitfalls:

1. Stretching of hamstrings, quads and calf muscles (all are very tight, hamstrings are particularly short).

    Purpose: Tight muscles lead to more rapid increases in force production. A more elastic muscle would then logically absorb the force over a longer period of time.

    Pitfall: If the muscle is tight from irritation of the joint (which is almost always the case), stretching proves to be exceptionally frustrating. You're flexible right after the stretching but within hours or days, you're just as tight as before the stretch.

2. Theraband balance exercises and quad strengthening exercises (straight leg raises, partial squats etc.) - all outside the pain zone.

Purpose: Stronger muscles help protect the joint.

Pitfall: The force required to fatigue the muscle is typically greater than what the joint can withstand. You either end up with a sore, swollen joint or muscles that have gained little strength.

 3. Molded orthotics for running and every-day shoes.

Purpose: Orthotics alter the movement of the leg (tibia and femur) via the foot thereby reducing the pressure under the patella (kneecap) and improving general alignment of the leg.

Pitfall: Small changes in foot alignment can lead to large changes in joint pressures sometimes for the better and sometimes not. Secondary complaints of lower back or hip pain are common.

4. Strapping/taping instructions for when I need/want to exercise with reduced discomfort.

Purpose: Reduces pain by altering sensory input to the brain.

Pitfall: You have to wear tape and unless your exercise is designed to improve the joint health, you may exercise too hard and not know it....until later.

The missing ingredient is an exercise regimen targeting the soft joint surface. Almost every exercise program that you find for PFS targets muscle (quadriceps strengthening, stretching of the hamstrings, etc.) and having stronger muscles is helpful but weak muscles are not the primary problem. The muscular weakness is in response to the changes in the joint. Some clinicians argue that cartilage does not respond to exercise; that it is biologically inert. However, there is ample scientific evidence proving that cartilage does respond like other biologic tissues of the body (muscle, tendon, ligament, bone) as long as the motion-force combination is within a certain range. You may not be able to regenerate articular cartilage with exercise but you can certainly improve the health of the injured or diseased cartilage. And, healthier cartilage translates into increased physical capability.

The ideal combination is low force (no greater than 50% of of your identified Load Tolerance - our e-booklet, Torn Meniscus, provides more detail on Load Tolerance) combined with very high repetitions (thousands) to facilitate biologic adaptation of the cartilage. Week by week, your Load Tolerance should increase and typically within six to nine months, reach full body weight (some people have been able to accomplish this in two to three months).

Once you address the core issue, joint health, the other treatments become even more effective. So, my opinion is to target the joint first, muscles second, and other treatments third (taping, orthotics, etc.)

Doug Kelsey

Roos, E. M. and L. Dahlberg (2005). "Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis." Arthritis Rheum 52(11): 3507-14.

Hip Pushups

Doug -- Is it safe to do hip push ups instead of the bird dog?  Here is an example video link:

http://www.posetech.com/video/index.php/weblog/2005/11/

As for the hip push ups - I don't know of any studies that have shown this drill to be safe or unsafe in terms of disc or joint compression unlike the bird dog position. But, from watching the video, here are my thoughts:

1. This drill would not be my first choice to help people develop muscular control of the spine. It is a high level drill requiring control and coordination of the spine, hips, and upper quarter.
2. The lumbar spine moves through a large amount of extension. For some people, this could create high levels of joint compression if they lack the range of motion and result in lower back pain or referred pain in the buttocks, hips, or lower extremities. In the bird dog, the spine moves very little while the muscles surrounding and controlling the spine contract.
3. The speed of the drill will influence the magnitude of compression. Slower speeds will be safer.
4. In the video, notice the left scapula (shoulder blade) of the woman performing the drill. In the sequence where one leg and the opposite arm are on the ground, she has poor control of the scapula ( if you look closely you will see the scapula protrude off the rib cage) indicating that the drill is too difficult at least for her upper quarter.