Monday, November 29, 2010

Arthritis - Part Three

Supper time at the old triathletes home

 Making it to Kona    (written on the Big Island)

"And another one's gone, and another one's gone, and another one bites the dust, heh heh."  You know who sang these words.  But, earlier in his career, singer Farrokh Bulsara (you now know him as Freddie Mercury) was going nowhere in a band called Sour Milk Sea.  He took a look at his past, present and unpromising future, and made the changes he felt were required to reach the top.  I guess the question is...are you willing to make the sacrifices Freddie made to get here?  But first, answer these three questions:  1) Do I have  reasonable chance to qualify or do I just impress myself when I tell others "I'm training for Kona?"  2) Will my personal/professional life suffer too greatly if I take on this goal?  Does my spouse/significant other agree with this biased assessment?  3) Is it worth it in the end and what will have been the cost - how many irretrievable kids soccer games will I have missed?  (The 70.3 distance is to some the perfect race.  It takes a fair amount of training - but not your life - to finish respectably, you're not walking death the next day...or two. Also, it's easy to keep the family involved without dipping into the college savings account for airfare.)  Food for thought.

Parts one and two of this arthritis thread have covered the general pathophysiology of the degenerative process, anatomical findings and PAIN. When it comes to procedure specifics, arthroscopy was reviewed in the 8/25/2010 blog, microfracture originally done 3/7/2009, and bone/cartilage transplants (OATS) in that of 11/13/10.  I reviewed joint replacement in triathletes 7/7/2010 and the host of issues that diagnosis and operation bring forth.  

 I actually spent a good bit of time on the phone tonight with an experienced triathlon coach scheduled for knee replacement surgery in January.  This is a man who already knows the triathlon game and who's done a great deal of research on artificial joints.  The main point I tried to get across to him was that regardless of TV ads or the skill of his surgeon, he will not have the same knee when all is said and done.  He may get a terrific result, but he'll notice at least small differences in joint function.  His choices of athletic activity may have to take this joint into account on some level.  Good luck, Coach!

So, this leaves us with conservative care. You don't immediately (if ever) want an operation and would like to take steps to diminish or eliminate pain while maintaining function. There are many volumes devoted to care of the arthritic patient, even an entire medical subspecialty - Rheumatology - so I'll just touch on a few things. As with most medical issues, an accurate diagnosis is an essential starting point. Does your arthritis affect only the joints or perhaps other body parts? An educated patient has the best chance to retard progression of the disease while maintaining the highest quality of life. Learn what you can about the problem and be your own best advocate. Some would say this could be true of any illness or injury and I'd tend to agree.

This may be accomplished through a host of options including weight loss, life style modification, changes in activity choices, joint protection, medications or injections, etc. Trying to balance the seemingly opposite goals of doing well in one's age group in a race as opposed to getting a damaged joint to last as far into the future as possible can be a challenge. In short, just like the triathlon coach facing knee replacement, do your research, ask your physician the right questions, and take charge of your own body. You are a triathlete after all!



Saturday, November 20, 2010

Knee Arthritis Part Two -Pain!

Bob Scott

" 'Bill I believe this is killing me!' as the smile ran away from his face."    Billy Joel

This is the second in a series of three pieces on arthritis.  We hear so much about "degenerative change" but it's causes are not always well understood. Those who have it know one thing - it hurts!

Although there are approximately 100 different varieties of arthritis, many accompanying other disease processes you've heard of like Lupus or Lymes Disease, Osteoarthritis is by far the most common. We think of  it as an old persons problem (old being a relative term in triathlon - just ask Bob Scott (above), Kona course record holder with a 12:59 when he was 70!)

Certainly arthritis is more common in the over 65 crowd but it's prevalence begins to increase by age 50 in men and, unfortunately, age 40 in women.  It's frequently a progressive problem which ends up with joint pain, swelling and stiffness, and can limit one's quality of life.  Three fourths of adults over 70 will demonstrate some degree of arthritis on plain x-ray.  Over time, the joint lining cartilage is eroded down to bone leading to pain, disability and narrowing of the joint to the point where it could become "bone on bone."

The drawing below shows the basic anatomy of a right knee, particularly the femur, the upper bone.  The cartilage lines the end of the bone and is normal, smooth and intact on the left side.  But, just to the right in the area labeled arthritis, you see that there are stellate cracks, with wear down to expose the underlying bone This might be the location of an injury in the past. Or, perhaps the athlete had a meniscus injury/removal earlier in life.  It's a lot more common than you might think. 

This photograph is what an arthritic femur would resemble at arthroscopy. Rather than being lovely and smooth, it looks more like an old tennis ball!

The function of the joint worsens over time as the disease process progresses.  Knee pain and swelling, initially present only with activity, become an issue at rest.  Many will lose range of motion and find their lives restricted by the joints lack of mobility.  I've had patients over the years report being "held hostage by the pain" or "a prisoner of my knee." 

If left unchecked, the joint ultimately wears out completely as shown on the x-ray below.  The black space between the bones on the left represents the normal cartilage space, but on the right, the bones are touching. This represents end stage disease.  One of the options for this patient, if symptomatic enough and a failure to conservative care, would be replacement.  As you'd imagine, triathlon probably isn't on the list of recommended activities following an operation of that magnitude.
  Next week, part three, options.


Saturday, November 13, 2010

Knee Arthritis, Continued - Aging (Over 30) Triathletes Take Note

Sister Madonna Buder sets the example for us all

"You're not shy, you get around, you wanna fly, don't want your feet on the ground. You stay up, you won't come down..." Foreigner

Of the over 100 blogs that I've done, the one that has generated the most interest was about arthritis of the knee and a procedure known as microfracture, 3/7/2009. This is an arthroscopic operation where an attempt is made to allow the damaged cartilage to heal itself. It's usually pretty successful but the results may not last forever. In cases where microfracture is considered inappropriate, Orthopedic Surgeons have other arthroscopic tricks that can hopefully extend the life of the knee. One of these involves transplantation of bone and cartilage plugs from one part of the knee to another.

But first, a little of the basics. The femur is the upper of the two bones that make up the knee joint. The bony surfaces are covered with articular cartilage (that white-pearly grey stuff at the ends of turkey bones) to make joint contact smooth and frictionless...until there's an injury or just wear and tear. This wear and tear would also be known as arthritis, or osteoarthritis. It's the deterioration of this supportive cartilage, pretty important stuff, which, although it's pretty hard, is slick enough to allow the bones to glide, one on top of the other. 

Cartilage is also a pretty good shock absorber.  If the cartilage wears to the bone, so called end stage arthritis is present and usually accompanied by significant pain. You might ultimately find yourself headed down "Joint Replacement Lane".

                                                                             So who's at risk for arthritis? The obese, females more than males, those with a positive family history of arthritis, smokers, and people who've had some type of injury to the joint just to name a few.

Surgeons have been doing bone and cartilage transplants for over 100 years divided into two groups: taking the tissue from a donor (allograft), usually deceased, or using the patients own tissue (autograft). I'll only discuss autografts today.

As seen in the picture above, plugs of cartilage covered bone are harvested from an out of the way area of the knee, and then placed mosaic-style in the prepared area of arthritis.  Great care is taken by the surgeon to get the size and location of each plug correct as it can spell success or failure of the operation. Following the case, weight bearing on crutches is the norm until it's felt that healing has taken place.  This technique is offered by many Orthopedic Surgeons.  If it were something you were considering, just make sure your doc does a lot of these as, take it from the voice of experience, it can be pretty easy to screw up until you learn it cold.

Friday, November 5, 2010

"I Felt So Good, Like Anything Was Possible"

Tom Petty and the Heartbreakers, Runnin' Down a Dream

The finish line in Kona about 12 hours after race start.

"ANYTHING IS POSSIBLE" This is one of the catch phrases of Ironman, one you hear frequently in Hawaii. You both hear it as well as see it. Some even live it.

There are so many heart warming stories that come out of this race each year. A good number of the first timers do not meet their expectations and on the morning after the race, honest evaluations of the heat and conditions seep into the conversations for the first time. "Mother Nature always bats last," or some such phrase might be overheard. In spite of this, the athletes share this common bond with the island as they lean back, close their eyes and recall particular portions of their day...both bad and good. And then they smile. That wry smile that comes only with experience.

The above photo is from ALII DRIVE, the finish line, where so many stories evolve. You hear them on race night, "I was just cruising down Alii Drive, man!," or at the Finishers Banquet, "The huge party at midnight at the finish line on Alii Drive was just awesome." Alii Drive, milepost zero, where it all starts and finishes.

By any other name it will always be Alii to the finishers:

NOVEMBER - Dreaming and planning time. (Part one)

You know how on January 2nd, when you can't get a locker at the health club or gym, and you're used to having light conversations with the regulars, but now there a lots of new folks and the air is almost festive with excitement? Unfortunately, you know from experience that in 60 days it'll be back to the same old crowd.

Triathletes are the same...dreamers all, and at this time of year, they're reviewing recent races, successes and failures, saying, "If I can train just a little harder next year I can take the age group...or get that slot..." Maybe what they need is to train smarter not harder, to reduce garbage work outs, to reduce injuries, or at least be able to train through them. Listen to the words of folks like Ben Greenfield who did an excellent USAT webinar 11/4 on how to minimize your down time getting a hold on injuries and returning to plan as quickly as is safe. In other words, create your plan mostly with your head and not your heart. Come race season, maybe if you're lucky, anything will be possible.

Next week, back to business as the triathletes injury resource. Happy training everyone.