The View from Sports Center

Update on Partial Knee Replacement

2009-11-08T19:00:00-06:00

This is a guest post by Kim Wright, PT and her husband James (Jay) Butler, MD. Kim is a physical therapist who specializes in orthopedics and her husband is an orthopedic surgeon. They both practice in Houston, Texas. I asked Kim and Jay if they would share their knowledge and experience with knee osteoarthritis and knee replacement and they generously agreed.

The knee joint is composed of three compartments. They are the inside(medial), outside (lateral) and the kneecap (patellofemoral). Wear and tear on our joint surfaces occurs over time depending on activities we perform and injuries that occur. Some of us will have more wear and tear due to the alignment or posture of our legs. Knee alignment refers to the angle of your thigh bone from your hip to your knee and the angle of your shin bone from your knee to your ankle. Your foot alignment is an angle formed from your heel to your forefoot. Terms such as knockneed, bowlegged and pronation refer to these angles. The angles influence how the force from the weight of your body and activities like running or hiking is distributed through your joints.

If you tend to be knockneed, bowlegged or if you tear a meniscus (shock absorbing pad between the bones) or suffer a fracture, the forces can be increased in one of the compartments. The extra force is transmitted to the bone and the overlying cartilage (articular surface). Given enough time, this surface wears away and the bone can become exposed and painful. This wearing away of the articular surface is called chondromalacia (arthritis). It is usually graded I-IV with I being the mildest degree of damage. When the damage progresses to stages III and IV the bone is actually becoming exposed and this is when pain and swelling occur and simple life activities such as walking, squatting and stairs become difficult.

When any of the three compartments suffer significant wearing of the articular surface causing Grade IV chondromalacia, the doctor may suggest a partial joint replacement. Partial joint replacements are ideal for patients with isolated Grade IV chondromalacia in only one compartment. This usually occurs in younger patients 40-60. Patients with a lot of arthritis in one compartment and some in the others may still have a certain degree of pain and swelling after surgery from the remaining arthritis. This is why a careful examination and selection process is critical for a good outcome. There are unicompartmental replacements ( ”Uni”) for the medial (inside), lateral (outside) and patellofemoral (kneecap) compartments. In contrast, a total knee replacement replaces all three compartments.

The surgery involves replacing the two sides of the bone of the damaged compartment with metal and plastic components. If you have medial or lateral compartment arthritis, and this has made your leg a little knockneed or bowlegged, the placement of the components will correct the alignment. The surgery involves an incision on the front of the knee.

The recovery is similar to a total knee replacement except it is usually with less pain and is faster. It involves a short stay in the hospital (2-3 days), one-two weeks using crutches or a walker and then 4-6 weeks of physical therapy. Someone with a unicompartmental replacement should expect to regain full straightening and almost full bend of the knee as compared to their normal knee during the first 4-6 weeks after surgery.

Sports are allowed with a unicompartmental replacement. Sports not involving repetitive high impact activities such as jumping, running and cutting are the best. For example, many patients return to walking, biking, hiking, light doubles tennis, weekly game of softball or baseball, dancing, gym workouts, exercise class. Younger patients may choose to return to running and other more strenuous sports, but this may lead to early deterioration of the plastic (polyethylene) component. Like all joint replacement and arthritis patients, individuals with a unicompartment replacement should maintain a healthy weight and perform exercises that promote good joint health regularly. This will help prevent wearing of the plastic component and reduce progression of less severe arthritis that may exist in other parts of the joint.

A unicompartment replacement should last about 10-15 years before needing a tune up. Sometimes the unicompartment replacement is just a time grabber for someone who may be destined to a total joint replacement. For other patients that actually fall into the “isolated” arthritis category it can be the last replacement they need. All joint replacements have a similar life expectancy before revisions are needed and this is usually stated as 10-15 years on average. There are two reasons the unicompartment replacement may need to be revised over time. Pre-existing arthritis in other parts of the knee can progress and the plastic component can wear out. If other parts of the knee progress to Grade IV chondromalacia (arthritis) the unicompartment replacement can be converted to a bicompartmental replacement for the onset of kneecap arthritis or a total knee joint for generalized arthritis development in the remaining two compartments. As with any surgery, but especially one that is performed on an isolated group of patients, ask your doctor why you qualify and ask how many of these procedures they have performed and their specific outcomes.

For more information on unicompartment replacements you can go to the website for the brand of prosthesis your physician uses or as an example go to www.biomet.com and choose patient and caregiver section, joint replacement, knee pain, knee joint replacement or knee joint products. You will read both good and bad reports from actual patients as well as research articles. Just remember that there is a very select group of patients that are appropriate for this procedure that will do well over time. Talk with your physician about your qualifications.

For outcome information on custom patellofemoral replacements you can reference the article from James E Butler, MD; Robert Shannon, MD Orthopedics 2009, 32:81 or www.orthosupersite.com.

What We Can Learn from the Love Lab About Injuries - Part II

2009-11-02T19:12:00-06:00

Last week, I wrote about the parallels between the work done by Dr. John Gottman and overcoming an injury. This week, I'll cover the seven positive traits that couples possess and how you can use those traits in your quest to rebound from and injury or illness.

Dr. Gottman has found seven positive traits in couples who enjoy long lasting, vibrant and rewarding marriages. Here they are along with my interpretation pertaining to injuries or illness.

1. Enhance Your Love Maps. Emotionally intelligent couples know each other's hopes and dreams. They know the history of the other person, significant events, and keep up to date with events.

Enhance Your Injury Maps. To be successful in beating an illness or injury, you need to know your own history; the actions, choices, attitudes that may have contributed to your current situation.

2. Nurture Your Fondness and Admiration. Gottman's research shows that 94% of the time, couples who feel the other is still worthy of honor and respect inspite of their flaws are more likely to have a happy future. According to Gottman, this is one of the most critical elements in a rewarding and long-lasting marriage.

Nurture Your Fondness and Admiration of Your Self. When you persist in running on a leg with a stress fracture, or working out despite raging leg pain, you're not honoring and respecting your self. You're only hurting your self. Listen to what your body is telling you and respect it.

3. Turn Toward Each Other Instead of Away. Gottman found that a secret in developing lasting emotional connection is to find ways to turn toward each other every day. When your partner tries to get your attention or support, making the turn toward your partner and not away is key.

Turn Toward Your Injury or Illness Instead of Away. Denial is a protective emotional mechanism that buys us time while we figure out what to do but prolonged denial can turn an acute problem into a chronic one. When you have symptoms, pay attention to them.

4. Let Your Partner Influence You. Couples who enjoyed the happiest marriages were those who found common ground, shared power and decision making and respected each others feelings and opinions.

Let Your Injury / Illness Influence You. Believe it or not, you can learn a lot from an injury - about your self, your body, healing. But, that only happens if you allow it to. You have to find some common ground - something between what you've lost and what you have - to launch something new and great.

5. Solve Your Solvable Problems. Gottman suggests solving the things that can be solved by using the following techniques:

Complain but don’t blame. You can complain about something, although be careful or you may end up with the whine flu, but try not to blame your predicament on someone else even if it is truly not your fault. Blaming blocks you from moving forward. Forgive, let go.
Make statements that start with “I” instead of “You.” Make your feelings and needs known rather than what someone else must do to fix your situation.
Describe what is happening, don’t evaluate or judge. One of my favorite stories about accepting, "what is" is here. Injuries carry a certain reality that you must accept to get past. Judging that reality doesn't help.
Be clear, polite and appreciative. When you hurt or don't feel well, it can be very difficult to remain polite and appreciative. Try remembering that the people around you who want to help you will be more likely to do so if you're not a Grinch.
Don’t store things up. Tough one for me. Finding a balance between talking about frustrations or lack of progress or recurring symptoms and not feeling like I'm whining is hard. But. not talking or sharing things creates a toxic emotional soup. You can always write things down in a journal if talking makes you too uncomfortable.

6. Overcome Gridlock. Gottman has found that ending gridlock doesn’t always mean solving the problem, but rather moving toward discussion. The steps he suggests are:

Learn to uncover your partner’s dreams. Well, for an injury it's uncovering your won dreams. Injuries can rob you of your future by seducing you into worrying. The more time you spend worrying, the less time you'll spend working on the very things that will lead you to your dreams.
Understand why each of you feels so strongly about the gridlocked issue. For an injury, understand why you feel so strongly about the gridlock - the lack of improvement or change you expect. Most clients I've seen have had an injury for years and then expect all to be well in a few weeks. It's not only the unrealistic expectations that are at fault. It's also your reaction to the situation. Why does it upset you so much? Once you can answer that, you'll feel much better.
Soothe each other to avoid flooding. Use pain relieving techniques, relaxation techniques to ease your discomfort. Be kind to your self.
End the gridlock by making peace with the issue, accepting the differences between you, talking without hurting each other and compromising. You have to find a way to make peace with your injury or illness without feeling like you've given up. You can still work toward a goal or dream while acknowledging that today you're not there. I'll admit that this is tough to do. I'm about 20 months post-injury and would like to believe I can do what I want, when I want, how I want but I can't. I can't sit in certain chairs or stand in one place too long without symptoms in my hip or leg. Yes, it's mild and temporary and improving, but it's still there.

7. Create Shared Meaning. Couples who thrive seem to be able to speak candidly yet respectfully about values and dreams. They're able to respect the dream they each have but recognize they may not both share the same dreams.

Create Shared Meaning About Your Injury. When you can talk about your injury, what it has meant to you both positively and negatively, and still "see" your dream, you create a deeper meaning to the experience. Probably one of the most well known individuals to have done this was Christopher Reeve. He was candid about his injury yet held onto the hope that one day we would find a cure for spinal cord injuries. The injury and his hope created value and meaning in his life.

Overcoming an injury can be a daunting task at times. If you feel this way, try going through this list to make a potentially tough situation more tolerable and rewarding.

What We Can Learn from the Love Lab About Injuries

2009-10-26T12:22:00-05:00

Dr. John Gottman from the Relationship Research Institute, also referred to as The Love Lab, in Seattle, Washington claims that within five minutes, he can predict with 91% accuracy whether a married couple will enjoy years of marital bliss or crash and burn.

He and his team, after studying hundreds of couples and scientifically scrutinizing their interactions, have found four negative qualities that predict divorce and seven positive that predict success.

As I read these, it struck me that these qualities, both positive and negative, are remarkably similar to those of people who overcome an injury and those who don't.

First, the negative:

Criticism: Global negative statements about your partner’s character or personality.

Global negative statements about your injury or situation; failure to find positive changes no matter how big or small.

Contempt: Sarcasm, cynicism, name-calling, eye-rolling, sneering, mockery and hostile humor can be poisonous because they convey disgust.

"It won't make any difference anyway...that'll never work..."

Defensiveness: This is a way of blaming your partner and can escalate the conflict.

Blaming others for your predicament; failure to accept choices you made that either created your problem or sustain it.

Stonewalling: A partner may disengage from the relationship, signaled by looking away without saying anything and acting as though he/she doesn’t care about what the other is saying.

Ignoring symptoms, refusing to discuss or acknowledge the severity of the problem; "It's not that bad....I'm fine."

According to Gottman, the presence of these four qualities in a relationship predict the end of the relationship with an 82% degree of accuracy. I don't know of any similar research in the injury field but I've said many times that the key to overcoming an injury does not rest primarily in the technical domain. It's not in the head where you win the battle. It's in the heart.

You have to focus your thoughts and energies on a positive frame of mind, be willing to face the issues, take responsibility, and be grateful for the improvements no matter how small to over come an injury or the after effects of surgery. If you don't, you won't fully recover.

And what about the seven qualities that build a great marriage and enhance your chances of recovery from injury?

Coming soon.

Lower Leg (Peroneal) Tendonosis: Part II

2009-10-22T11:25:56-05:00

In my last post, I covered the Five Keys to Solving Lower Leg (Peroneal) Tendonosis and I mentioned at the end of that article that I would describe a few drills.

Just as a reminder, the drill selection is driven by at least three things: the nature of the injury (tissue or tissues involved), the severity and irritability or what we refer to as the "stage", and the mechanics of the involved structures. In Chuck's case, the tissue is the peroneus longus and brevis, the stage is unknown, and the mechanics are deceleration of the lower leg over the foot in a weight bearing position.

For someone who has symptoms either at rest or very quickly with activity, one of the drills we might choose would be a bilateral squat with a less than body weight load. We prefer to use a Total Gym to reduce the bodyweight force.

After testing to find out the appropriate level, the client would perform 3-5 minutes of squats with a focus on pressing the ball of the foot into the footplate. This puts the dosage close to 100 reps per set. The peroneus longus plantarflexes and everts the foot which you can create by simply applying force into the base of the first metatarsal (ball of the foot). Although the foot doesn't move, you'll increase the tension in those muscles from just trying. Near the end of the set, you should feel a mild degree of fatigue and pain or discomfort.

A progression would be to move to a sidelying position and place the foot on a foam pad to create an inverted position (or supinated). Now, as Mike squats, he tries to pronate the foot by pressing the ball of the foot into the foam pad. This increases the load on the peroneus longus and brevis.

For less irritable or severe cases, we might choose a split squat with a lateral vector. The vector or line of force pulls the leg away from the midline of the body (which is why we call it a lateral vector). In the picture, you can see that at rest, Mike's leg has been pulled out and even rotated out a bit. His job during the drill was to press the great toe into the floor and keep the lower leg straight which he did. And, his comment was that he could feel the muscles on the outside of his leg working fairly hard.

The dosage for this drill is lower than the bilateral squat since the load is higher. It's still fairly high, from muscle training standards, at 20 to 30 repetitions per set. And, we want both a moderate degree of fatigue and pain at the end of the set(s).

The difficult part of this process is finding the right mix of load and reps and pain. We often have to coach clients that all pain is not bad. Some pain is actually good for you as in the case of tendonosis.

But, since all pain is emotional, you have to be careful in applying this concept to your self or someone else. It's just a lot easier to have a coach - not necessarily right there with you all the time - but someone who can help you interpret what you're doing and feeling.

Thanks to our physical therapy student intern, Mike Coller, from the University of Wisconsin, for helping me with this post by generously serving as a subject and asking some great questions.

Five Keys to Solving Lower Leg (Peroneal) Tendonosis

2009-10-20T07:00:00-05:00

Hi Doug...

I was introduced to your practice and subsequently your blog(s) by a local (Austin) Neurologist whom you treated successfully. You receive our praise in absentia at our annual Fall Rocky Mountain hunting trips which involve hiking over rough terrain (as opposed to TX style hunting blinds). I use your advice remotely from Montana to treat various arthritic joints and keep my 62 year old decrepit body active. I have studied your therapy recommendations for tendonosis of of various tendons but have been unable to infer from those a treatment for my disabling peroneal tendonosis (it makes me want to scream while sidehilling or walking on rocks....bad for hunting). I know that it is a somewhat rare diagnosis but I would appreciate a blog dedicated to this diagnosis and its treatment.

Thanks,

Chuck

P.S. I haven't tried downhill skiing yet...it will be interesting to see if the rigid boots stabilize the ankle enough to minimize the pain.

Thanks for your note Chuck and your question. Here are my thoughts on your situation.

The more irritable the condition, the lower the load and the higher the volume you'll need. If your leg hurts quickly and takes a while to subside, days for example, you'll need low loads and high volume of reps to alter the tension capacity of the tendon. You have to sneak up on it and nudge it into a healthier state. The rep range is around 100 reps / set with low levels of fatigue and very mild discomfort. If you can hike for a hour or two and the symptoms subside within a few hours, then you can use a higher load and lower volume - around 30 reps per set with moderate fatigue and discomfort.
Move your body over a stable, fixed foot. The peroneus longus muscle likes to restrain motion of the leg and provide stability to the arch of the foot rather than produce motion even though the classical definition of the muscle action is to produce eversion (moving the foot sideways) and plantarflexion (pointing the foot). This is because anatomists define muscle action as creating motion from the insertion of the muscle toward the origin. The peroneus longus inserts on the bottom the foot near the first metatarsal. So, if you flip the action around so the motion is from the origin to the insertion, the tibia moves back and down. When your foot is on the ground, the muscle is pulling back on the tibia to keep it from moving to quickly over your foot. This is, as you noted, the time when you're apt to feel the symptoms - when your foot is on the ground and you're decelerating your center of gravity as in walking down hill sideways or over uneven surfaces like rocks. Once your leg tolerates a stable surface, you can then advance to unstable surface training.
Train to pain. You have to train hard enough that you produce some symptoms and this is where it's often tough to do alone. What's too much? What's not enough? Well, the intensity is too much when you compromise your motion and it's too little if you don't hurt at all. You want the symptoms to show up near the end of each set. And, ideally you want motions that produce the symptoms in real life. You use the very thing that bothers you to heal you but you control the load.
Train the hip. Your hip external rotators counter the pull of gravity and the collapse of the leg toward the ground when doing things like walking, climbing and hiking . The stronger your hips are the more they will help the peroneal muscles do their job.
Poke and Prod. Sometimes, I'll use a manual technique to induce an inflammatory reaction. The technique itself is probably less important than the intensity and duration of it. Tendonosis is a condition of tissue weakness. If you can create a mild inflammatory reaction (and this is what some of the drills do as well), you will jump start the production of collagen which is what the tissue needs. Rolfing, Deep Tissue Massage, certain forms of Myofascial Release, and Graston Technique all can create an inflammatory reaction (This is also the framework for Prolotherapy, an invasive technique used to promote soft tissue healing.) You'll need a professional to help you with this though.

As for snow skiing, the boots will help but your foot still works inside the boot as you carve in the snow to turn one way or the other. So depending on how irritable your tissues are, you may still hurt a fair amount.

Last thing specifically for you Chuck. If you have arthritic joints, such as a knee or hip, you'll want to recondition those joints so you get as much help as possible for your foot / ankle. Sometimes one area of the body ends up working too hard because the arthritic joints dial down the muscle power of the muscles around the effected joint (s). This is called arthrogenic inhibition. So, in the knee for example, you can lose some strength in the quadriceps, hamstrings, and even the gastrocnemius. The gasctrocnemius is a direct synergist for the peroneus longus meaning it helps it do its job.

Next time, I'll go over some drills for this condition.